Healthcare Provider Details

I. General information

NPI: 1518939297
Provider Name (Legal Business Name): LAWRENCE NATHAN COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 SIXTH AVE. UNIT 606
SAN DIEGO CA
92103-2122
US

IV. Provider business mailing address

2500 6TH AVE UNIT 606
SAN DIEGO CA
92103-2122
US

V. Phone/Fax

Practice location:
  • Phone: 619-990-5656
  • Fax: 619-432-1853
Mailing address:
  • Phone: 619-990-5656
  • Fax: 619-432-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG27092
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG27092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: