Healthcare Provider Details

I. General information

NPI: 1295700367
Provider Name (Legal Business Name): CLYDE A. COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 CALIFORNIA DR C/O MEDICAL STAFF OFFICE
YOUNTVILLE CA
94599-1412
US

IV. Provider business mailing address

PO BOX 942895
SACRAMENTO CA
94295-0001
US

V. Phone/Fax

Practice location:
  • Phone: 707-944-4772
  • Fax: 707-944-5052
Mailing address:
  • Phone: 916-654-0080
  • Fax: 916-653-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG34593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: