Provider Demographics
NPI:1477547164
Name:COOPER, ANDREW D (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:COOPER
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 1:1874 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3118
Mailing Address - Country:US
Mailing Address - Phone:801-487-2873
Mailing Address - Fax:
Practice Address - Street 1:24 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1500
Practice Address - Country:US
Practice Address - Phone:801-533-2002
Practice Address - Fax:801-323-9546
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5898557-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT122061Medicare UPIN
UTC800410Medicare ID - Type Unspecified