Healthcare Provider Details

I. General information

NPI: 1932106572
Provider Name (Legal Business Name): THOMAS COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 WORCESTER ST
WELLESLEY MA
02481-5420
US

IV. Provider business mailing address

230 WORCESTER ST
WELLESLEY MA
02481-5420
US

V. Phone/Fax

Practice location:
  • Phone: 781-431-5255
  • Fax: 781-431-5329
Mailing address:
  • Phone: 781-431-5255
  • Fax: 781-431-5329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number55056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: