Healthcare Provider Details

I. General information

NPI: 1871562975
Provider Name (Legal Business Name): JEFFREY C COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-243-4450
  • Fax: 574-243-4405
Mailing address:
  • Phone: 574-243-4450
  • Fax: 574-243-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01043721A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: