Healthcare Provider Details

I. General information

NPI: 1194729525
Provider Name (Legal Business Name): ROBERT WAYNE COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date: 03/16/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

475 N HIGHWAY 25 W # WN SUITE 100
WILLIAMSBURG KY
40769-1576
US

IV. Provider business mailing address

PO BOX 247
JELLICO TN
37762-0247
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2933
  • Fax: 606-549-3036
Mailing address:
  • Phone: 606-549-2933
  • Fax: 606-549-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18598
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: