Healthcare Provider Details

I. General information

NPI: 1407887797
Provider Name (Legal Business Name): COOPER LOOMIS TERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 AZALEA DR SUITE 102
OXFORD MS
38655-7905
US

IV. Provider business mailing address

497 AZALEA DR SUITE 102
OXFORD MS
38655-7905
US

V. Phone/Fax

Practice location:
  • Phone: 662-513-2000
  • Fax: 662-513-2001
Mailing address:
  • Phone: 662-513-2000
  • Fax: 662-513-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number14854
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number14854
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: