Healthcare Provider Details

I. General information

NPI: 1568646818
Provider Name (Legal Business Name): ROGER SCOTT COOLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
US

IV. Provider business mailing address

3998 FAIR RIDGE DR SUITE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-2000
  • Fax: 757-826-9028
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.016732
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35091962
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101253918
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: