Healthcare Provider Details

I. General information

NPI: 1740846989
Provider Name (Legal Business Name): COOPER RANDALL TROST DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E APPLE ST STE 3800
DAYTON OH
45409-2902
US

IV. Provider business mailing address

128 E APPLE ST STE 3800
DAYTON OH
45409-2902
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2007
  • Fax: 937-208-2752
Mailing address:
  • Phone: 937-208-2007
  • Fax: 937-208-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number58.031129
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: