Provider Demographics
NPI:1497730832
Name:COOPERSMITH, ILENE Z (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:Z
Last Name:COOPERSMITH
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 1:2101 MERMAID AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2517
Mailing Address - Country:US
Mailing Address - Phone:718-266-1676
Mailing Address - Fax:718-266-4528
Practice Address - Street 1:2101 MERMAID AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2517
Practice Address - Country:US
Practice Address - Phone:718-266-1676
Practice Address - Fax:718-266-4528
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105068208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00183284Medicaid
NY841261Medicare ID - Type Unspecified
NY00183284Medicaid