Healthcare Provider Details

I. General information

NPI: 1306807938
Provider Name (Legal Business Name): ROGER COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 MARTIN LUTHER KING JR BLVD ST MICHAEL INFECTIOUS DISEASE
NEWARK NJ
07102-2011
US

IV. Provider business mailing address

PO BOX 36 ST MICHAEL INFECTIOUS DISEASE
ROSELAND NJ
07068-0036
US

V. Phone/Fax

Practice location:
  • Phone: 973-877-2586
  • Fax: 973-877-2661
Mailing address:
  • Phone: 973-877-2586
  • Fax: 973-877-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA35197
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: