Provider Demographics
NPI:1326135963
Name:COOPER, COLLEEN J (MD, MPH)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:J
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 24TH AVE S
Mailing Address - Street 2:SUITE 602
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1455
Mailing Address - Country:US
Mailing Address - Phone:612-273-6099
Mailing Address - Fax:
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:SUITE 602
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-273-6099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26550207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245567600Medicaid
MNA94389Medicare UPIN
MN110002206Medicare ID - Type Unspecified