Healthcare Provider Details

I. General information

NPI: 1558341891
Provider Name (Legal Business Name): JAY M. COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CANAL ST SUITE B
KING CITY CA
93930-3431
US

IV. Provider business mailing address

PO BOX 667
KING CITY CA
93930-0667
US

V. Phone/Fax

Practice location:
  • Phone: 831-385-1280
  • Fax: 831-385-1285
Mailing address:
  • Phone: 831-385-1280
  • Fax: 831-385-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA69042
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA69042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: