Provider Demographics
NPI:1366624124
Name:GEORGE L COOPER MD
Entity Type:Organization
Organization Name:GEORGE L COOPER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-323-2002
Mailing Address - Street 1:2139 VALLEYGATE DR STE 101A
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3666
Mailing Address - Country:US
Mailing Address - Phone:910-323-2002
Mailing Address - Fax:910-323-3477
Practice Address - Street 1:2139 VALLEYGATE DR STE 101A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3666
Practice Address - Country:US
Practice Address - Phone:910-323-2002
Practice Address - Fax:910-323-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
NC1226332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093AGMedicaid
NC891083NMedicaid
NC89093AGMedicaid
DB5891Medicare PIN
G11691Medicare UPIN
H19498Medicare UPIN
NC891083NMedicaid