Provider Demographics
NPI:1265491260
Name:COOPER, MICHELLE M (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2118
Mailing Address - Country:US
Mailing Address - Phone:864-288-5665
Mailing Address - Fax:864-277-9946
Practice Address - Street 1:24 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2118
Practice Address - Country:US
Practice Address - Phone:864-277-4420
Practice Address - Fax:864-277-9946
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10389Medicaid
U51096Medicare UPIN
SCD10389Medicaid