Healthcare Provider Details

I. General information

NPI: 1043790207
Provider Name (Legal Business Name): DYLAN M COOPER MD, PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET BI W2144
AUGUSTA GA
30912
US

IV. Provider business mailing address

1120 15TH STREET BI W2144
AUGUSTA GA
30912
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0180
  • Fax: 706-446-0077
Mailing address:
  • Phone: 706-721-0180
  • Fax: 706-446-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number37723
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16459
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: