Provider Demographics
NPI:1023014099
Name:COOPER, REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5621
Mailing Address - Country:US
Mailing Address - Phone:904-246-8684
Mailing Address - Fax:904-246-6878
Practice Address - Street 1:333 4TH AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5621
Practice Address - Country:US
Practice Address - Phone:904-246-8684
Practice Address - Fax:904-246-6878
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2008-09-02
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
FLME44431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15879Medicare UPIN