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General NPI Number Information
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NPI Number | 1083612352
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Entity Type | Individual
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Provider Name | RANDY WILSON COOPER M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/12/2005
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Last Update Date | 03/23/2022
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Provider Practice Location Address
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Address Line | 818 SAINT SEBASTIAN WAY STE 104
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City | AUGUSTA
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State | GA
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Zip | 30901-2652
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Country | US
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Telephone | 706-434-0130
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Fax | 706-434-0131
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Provider Business Mailing Address
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Address Line | PO BOX 1705
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City | AUGUSTA
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State | GA
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Zip | 30903-1705
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Country | US
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Telephone | 706-854-6008
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Fax | 706-854-6946
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 022737
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License Number State | GA
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