Provider Demographics
NPI:1154316495
Name:COOPER, RANDY I (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:I
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2149 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3494
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:
Practice Address - Street 1:7362 W THUNDERBIRD RD STE 103
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5028
Practice Address - Country:US
Practice Address - Phone:480-610-6152
Practice Address - Fax:480-610-6189
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ30432207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ722464Medicaid
AZ722464Medicaid
H09486Medicare UPIN