Provider Demographics
NPI:1437105392
Name:COOMER, CYNARA L (MD)
Entity Type:Individual
Prefix:
First Name:CYNARA
Middle Name:L
Last Name:COOMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2810
Mailing Address - Country:US
Mailing Address - Phone:817-250-6570
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE 420
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2810
Practice Address - Country:US
Practice Address - Phone:817-250-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236455174400000X
TXT5855208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02677549Medicaid
NY0761V1Medicare ID - Type Unspecified
NY02677549Medicaid