Healthcare Provider Details

I. General information

NPI: 1194922963
Provider Name (Legal Business Name): MARION LESLIE COOPER II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 01/12/2025
Certification Date: 01/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5133 RIVERS AVE
N CHARLESTON SC
29406-6338
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-1786
  • Fax:
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30037
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: