Healthcare Provider Details

I. General information

NPI: 1497701023
Provider Name (Legal Business Name): MICHAEL COOPERSTOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N KEENE ST
COLUMBIA MO
65201-6626
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-6921
  • Fax:
Mailing address:
  • Phone: 573-882-3974
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberR5666
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR5666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: