Provider Demographics
NPI:1477505063
Name:COOPER, KEITH E (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2808
Mailing Address - Country:US
Mailing Address - Phone:608-755-7960
Mailing Address - Fax:608-755-7873
Practice Address - Street 1:849 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2808
Practice Address - Country:US
Practice Address - Phone:608-755-7960
Practice Address - Fax:608-755-7873
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65886-21207Q00000X
IN02002249A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING50596Medicare UPIN
IN190040Medicare ID - Type Unspecified