Provider Demographics
NPI:1407850316
Name:COOPER, STEPHAN K (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:K
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 1:471 ASHLEY RIDGE BLVD.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106
Mailing Address - Country:US
Mailing Address - Phone:318-795-4770
Mailing Address - Fax:318-795-4775
Practice Address - Street 1:471 ASHLEY RIDGE BLVD.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-795-4770
Practice Address - Fax:318-795-4775
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03318R207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1158585Medicaid
LA1053315846OtherGROUP NPI NUMBER
LA180008739OtherRAILROAD MEDICIARE
LA5K0996742Medicare PIN
LAB89026Medicare UPIN
LA5K099Medicare ID - Type Unspecified
LA180008739OtherRAILROAD MEDICIARE