Provider Demographics
NPI:1518166289
Name:COOPER, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-937-3433
Mailing Address - Fax:315-470-5859
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-470-7364
Practice Address - Fax:315-470-5859
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY244186208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02901417Medicaid
NYP00427369Medicare PIN
NYRB4629Medicare PIN