Healthcare Provider Details

I. General information

NPI: 1841219326
Provider Name (Legal Business Name): MATTHEW R COOPERBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DIVISADERO ST BOX 1711
SAN FRANCISCO CA
94143-1711
US

IV. Provider business mailing address

1600 DIVISADERO ST BOX 1711
SAN FRANCISCO CA
94143-1711
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-7171
  • Fax:
Mailing address:
  • Phone: 415-353-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA79827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: