Provider Demographics
NPI:1215020763
Name:COOPER, KENT J (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:J
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 1:2401 S TUCKER AVE
Mailing Address - Street 2:STE. 2
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6609
Mailing Address - Country:US
Mailing Address - Phone:620-231-6280
Mailing Address - Fax:
Practice Address - Street 1:2401 S TUCKER AVE
Practice Address - Street 2:STE. 2
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6609
Practice Address - Country:US
Practice Address - Phone:620-231-6280
Practice Address - Fax:620-231-6342
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100086050AMedicaid
KSCOO2521Medicare ID - Type Unspecified
KS100086050AMedicaid