Provider Demographics
NPI:1376577890
Name:COOPER, KENNETH H (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
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 1:12200 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2223
Mailing Address - Country:US
Mailing Address - Phone:972-560-2667
Mailing Address - Fax:972-239-6649
Practice Address - Street 1:12200 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2223
Practice Address - Country:US
Practice Address - Phone:972-560-2667
Practice Address - Fax:972-239-6649
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD75502083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX840501OtherBLUE CROSS
TX840501Medicare ID - Type Unspecified
TX840501OtherBLUE CROSS