Provider Demographics
NPI:1013378652
Name:COOPERSTEIN, NOAH M (MD)
Entity Type:Individual
Prefix:DR
First Name:NOAH
Middle Name:M
Last Name:COOPERSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1284
Mailing Address - Country:US
Mailing Address - Phone:618-256-7311
Mailing Address - Fax:
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1284
Practice Address - Country:US
Practice Address - Phone:618-256-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine