Provider Demographics
NPI:1407025679
Name:DR. WESLEY D. COOPER, OPTOMETRIST, P.C.
Entity Type:Organization
Organization Name:DR. WESLEY D. COOPER, OPTOMETRIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PC
Authorized Official - Phone:970-249-3914
Mailing Address - Street 1:400 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5738
Mailing Address - Country:US
Mailing Address - Phone:970-249-3914
Mailing Address - Fax:970-249-7893
Practice Address - Street 1:400 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5738
Practice Address - Country:US
Practice Address - Phone:970-249-3914
Practice Address - Fax:970-249-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08765232Medicaid
CO0385143Medicaid
CO08765232Medicaid
COT60729COMedicare UPIN
COC804454Medicare PIN