Provider Demographics
NPI:1346723160
Name:COOPER, GARRY VERN
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:VERN
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 RONALD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-2156
Mailing Address - Country:US
Mailing Address - Phone:614-327-1388
Mailing Address - Fax:
Practice Address - Street 1:1921 RONALD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-2156
Practice Address - Country:US
Practice Address - Phone:614-327-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty