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General NPI Number Information
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NPI Number | 1568551414
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Entity Type | Individual
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Provider Name | SHELBY O. COOPER M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 10/10/2022
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Provider Practice Location Address
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Address Line | 207 N TOWNLINE RD STE 204
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City | LAGRANGE
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State | IN
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Zip | 46761-1325
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Country | US
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Telephone | 260-463-9470
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Fax | 260-665-7312
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Provider Business Mailing Address
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Address Line | 11109 PARKVIEW PLAZA DR # 117
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City | FORT WAYNE
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State | IN
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Zip | 46845-1701
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Country | US
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Telephone |
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Fax |
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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 | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 01021456
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 01021456A
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License Number State | IN
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