Provider Demographics
NPI:1497701023
Name:COOPERSTOCK, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COOPERSTOCK
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-882-3974
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-882-6921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR56662080P0208X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11588OtherBLUE SHIELD
MO9209005OtherUNITED HEALTHCARE
MO11588OtherBLUE CHOICE
MO102434OtherHEALTHLINK
MO200527802Medicaid
MO2086988101OtherKANSAS MEDICAID
MO969325236Medicare PIN
MO042010635Medicare PIN
MO2086988101OtherKANSAS MEDICAID