Provider Demographics
NPI:1073530655
Name:COOPERBERG, CHARLES IAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:IAN
Last Name:COOPERBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:COOPERBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4419 BEN FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2147
Mailing Address - Country:US
Mailing Address - Phone:919-477-3005
Mailing Address - Fax:919-477-5526
Practice Address - Street 1:4419 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2147
Practice Address - Country:US
Practice Address - Phone:919-477-3005
Practice Address - Fax:919-477-5526
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32098207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8924146Medicaid
C83342Medicare UPIN
205577Medicare ID - Type Unspecified