Healthcare Provider Details

I. General information

NPI: 1902253230
Provider Name (Legal Business Name): MARIA M COOPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 3B
ST AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

18228 N US HIGHWAY 41
LUTZ FL
33549-4400
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-1786
  • Fax: 813-321-1787
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME133785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: