Provider Demographics
NPI:1467487819
Name:COOPER, JOHN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:COOPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4242
Mailing Address - Country:US
Mailing Address - Phone:256-547-0406
Mailing Address - Fax:256-547-9663
Practice Address - Street 1:234 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4242
Practice Address - Country:US
Practice Address - Phone:256-547-0406
Practice Address - Fax:256-547-9663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-920-TA-487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51512390OtherBCBS AL
AL51096433OtherBCBS AL
AL51512390OtherBCBS AL