Provider Demographics
NPI:1205836590
Name:COOPER, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
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 1:6243 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3731
Mailing Address - Country:US
Mailing Address - Phone:718-507-4700
Mailing Address - Fax:
Practice Address - Street 1:6243 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3731
Practice Address - Country:US
Practice Address - Phone:718-507-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1617802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00967868Medicaid
A643370Medicare UPIN