Provider Demographics
NPI:1043203037
Name:COOPER, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:COOPER
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 1:22 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-2340
Mailing Address - Country:US
Mailing Address - Phone:860-739-4431
Mailing Address - Fax:860-739-9461
Practice Address - Street 1:22 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-2340
Practice Address - Country:US
Practice Address - Phone:860-739-4431
Practice Address - Fax:860-739-9461
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT030023OtherHEALTHNET
CT1243393Medicaid
CT010024339CT01OtherBS/BC
CT110006583Medicare PIN
CT1243393Medicaid
CT030023OtherHEALTHNET