Healthcare Provider Details

I. General information

NPI: 1073992087
Provider Name (Legal Business Name): COOPER JOHNSTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date: 06/17/2020
Reactivation Date: 07/08/2020

III. Provider practice location address

4122 N 17TH ST
PHOENIX AZ
85016-5922
US

IV. Provider business mailing address

22744 E MAYA RD
QUEEN CREEK AZ
85142-2834
US

V. Phone/Fax

Practice location:
  • Phone: 928-543-1515
  • Fax:
Mailing address:
  • Phone: 480-678-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number007402
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number007402
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: