Provider Demographics
NPI:1407887797
Name:TERRY, COOPER LOOMIS (MD)
Entity Type:Individual
Prefix:
First Name:COOPER
Middle Name:LOOMIS
Last Name:TERRY
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 1:497 AZALEA DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-7905
Mailing Address - Country:US
Mailing Address - Phone:662-513-2000
Mailing Address - Fax:662-513-2001
Practice Address - Street 1:497 AZALEA DR
Practice Address - Street 2:SUITE 102
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-7905
Practice Address - Country:US
Practice Address - Phone:662-513-2000
Practice Address - Fax:662-513-2001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14854207XX0005X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117049Medicaid
MSG03967Medicare UPIN
MS4204200001Medicare NSC
MSC02514OtherGROUP PTAN