Healthcare Provider Details

I. General information

NPI: 1790769230
Provider Name (Legal Business Name): BRUCE DAVID COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BRISTLECONE DR
FORT COLLINS CO
80524-2031
US

IV. Provider business mailing address

120 BRISTLECONE DR
FORT COLLINS CO
80524-2031
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-5209
  • Fax: 970-221-7165
Mailing address:
  • Phone: 970-224-5209
  • Fax: 970-221-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24912
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number24912
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: