Healthcare Provider Details

I. General information

NPI: 1356314066
Provider Name (Legal Business Name): JANE D COOPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STRAITS TPKE SUITE #301
MIDDLEBURY CT
06762-1836
US

IV. Provider business mailing address

1625 STRAITS TPKE SUITE #301
MIDDLEBURY CT
06762-1836
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-7281
  • Fax: 203-573-7230
Mailing address:
  • Phone: 203-573-9512
  • Fax: 203-568-2904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number030768
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: