Provider Demographics
NPI:1235581539
Name:COOPER, RANDAL LLOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:LLOYD
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 1:4951 S WHITE MOUNTAIN RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7827
Mailing Address - Country:US
Mailing Address - Phone:928-537-6700
Mailing Address - Fax:928-532-2199
Practice Address - Street 1:4951 S WHITE MOUNTAIN RD BLDG A
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7827
Practice Address - Country:US
Practice Address - Phone:928-537-6700
Practice Address - Fax:928-532-2199
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL14102207QA0000X
AZ57799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
AZ551329Medicaid