Provider Demographics
NPI:1477630929
Name:COOPER, CAROLYN (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:COOPER
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 1:1400 WEST STATE STREET
Mailing Address - Street 2:BLDG B, STE C
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906
Mailing Address - Country:US
Mailing Address - Phone:765-494-0111
Mailing Address - Fax:
Practice Address - Street 1:1 WALTER SCHOLER DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-6303
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8257
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100335050Medicaid
IN000001100839OtherANTHEM PROVIDER NUMBER
ING24811Medicare UPIN
IN160120EMedicare PIN
IN100335050Medicaid
IN000001100839OtherANTHEM PROVIDER NUMBER