Healthcare Provider Details

I. General information

NPI: 1578694030
Provider Name (Legal Business Name): LARRY J. COOPER, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W EAGLE DR
DECATUR TX
76234-3745
US

IV. Provider business mailing address

1001 W EAGLE DR
DECATUR TX
76234-3745
US

V. Phone/Fax

Practice location:
  • Phone: 940-627-7443
  • Fax: 940-627-7464
Mailing address:
  • Phone: 940-627-7443
  • Fax: 940-627-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberD2400
License Number StateTX

VIII. Authorized Official

Name: LARRY J COOPER
Title or Position: OWNER
Credential: MD
Phone: 940-627-7443