Provider Demographics
NPI:1003860891
Name:COOPER, TIMOTHY E
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 POMFRET STREET
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260
Mailing Address - Country:US
Mailing Address - Phone:860-928-2736
Mailing Address - Fax:860-928-6367
Practice Address - Street 1:330 POMFRET STREET
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260
Practice Address - Country:US
Practice Address - Phone:860-928-2736
Practice Address - Fax:860-928-6367
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400001999Medicare PIN