Healthcare Provider Details

I. General information

NPI: 1205836590
Provider Name (Legal Business Name): CHARLES L. COOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6243 WOODHAVEN BLVD
REGO PARK NY
11374-3731
US

IV. Provider business mailing address

6243 WOODHAVEN BLVD
REGO PARK NY
11374-3731
US

V. Phone/Fax

Practice location:
  • Phone: 718-507-4700
  • Fax:
Mailing address:
  • Phone: 718-507-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number161780
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: