Provider Demographics
NPI:1205842176
Name:COOPER, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:R
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-846-0620
Mailing Address - Fax:352-374-6103
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:BOX 100371
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-846-0620
Practice Address - Fax:352-374-6103
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17698207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50279Medicare UPIN
FL01985YMedicare PIN