Provider Demographics
NPI:1477654184
Name:COOPER, DIREESE MARY (DPM)
Entity Type:Individual
Prefix:MS
First Name:DIREESE
Middle Name:MARY
Last Name:COOPER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8603 GILBERT STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150
Mailing Address - Country:US
Mailing Address - Phone:215-248-1090
Mailing Address - Fax:215-248-1090
Practice Address - Street 1:6400 CLEARVIEW ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2040
Practice Address - Country:US
Practice Address - Phone:215-844-5688
Practice Address - Fax:215-844-5689
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC0058R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0123250001Medicaid
U16811Medicare UPIN
PA659296Medicare ID - Type Unspecified