Provider Demographics
NPI:1083612352
Name:COOPER, RANDY WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:WILSON
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-854-6008
Mailing Address - Fax:706-854-6946
Practice Address - Street 1:818 SAINT SEBASTIAN WAY STE 104
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2652
Practice Address - Country:US
Practice Address - Phone:706-434-0130
Practice Address - Fax:706-434-0131
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022737208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG22737Medicaid
GA000221625AMedicaid
GA000221625AMedicaid