Healthcare Provider Details

I. General information

NPI: 1205978970
Provider Name (Legal Business Name): MARY ALICE COOPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 CARLISLE BLVD NE
ALBUQUERQUE NM
87106-1317
US

IV. Provider business mailing address

204 CARLISLE BLVD NE
ALBUQUERQUE NM
87106-1317
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6522
  • Fax:
Mailing address:
  • Phone: 505-266-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92-201
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: