Provider Demographics
NPI:1073699773
Name:COOPER SIMON, GWEN MINDA (MD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:MINDA
Last Name:COOPER SIMON
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 1:502 E THOMASON CR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801
Mailing Address - Country:US
Mailing Address - Phone:334-749-0390
Mailing Address - Fax:334-742-9165
Practice Address - Street 1:502 E THOMASON CR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801
Practice Address - Country:US
Practice Address - Phone:334-749-0390
Practice Address - Fax:334-742-9165
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27869207V00000X
AL12501207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
51017248OtherBCBS
AL000017248Medicaid