Provider Demographics
NPI:1477531895
Name:KOOPER, GRACE N (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:N
Last Name:KOOPER
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 1:28 WILLIS DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-2066
Mailing Address - Country:US
Mailing Address - Phone:401-258-1667
Mailing Address - Fax:
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:808-941-7228
Practice Address - Fax:508-941-6401
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA783402083A0300X, 2084P0800X
RIMD093342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110055852AMedicaid
MA3139123Medicaid
MAG03926Medicare UPIN
MA110055852AMedicaid