Healthcare Provider Details

I. General information

NPI: 1609876366
Provider Name (Legal Business Name): BARRY J COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD #180B
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

1139 CONWYCK LN
SAINT LOUIS MO
63131-2630
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5252
  • Fax: 314-842-1524
Mailing address:
  • Phone: 314-842-5252
  • Fax: 314-842-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number34574
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: