Healthcare Provider Details

I. General information

NPI: 1619036951
Provider Name (Legal Business Name): ELLIS O. COOPER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LINE AVE SUITE 100
SHREVEPORT LA
71101-4644
US

IV. Provider business mailing address

1534 ELIZABETH AVE STE 301
SHREVEPORT LA
71101-4531
US

V. Phone/Fax

Practice location:
  • Phone: 318-635-3052
  • Fax: 318-635-3072
Mailing address:
  • Phone: 318-629-5001
  • Fax: 318-629-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number022842
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: