Provider Demographics
NPI:1518398916
Name:COOPER, JOHN ALLEN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALLEN
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N KINGSHIGHWAY BLVD APT 13F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1343
Mailing Address - Country:US
Mailing Address - Phone:314-669-5551
Mailing Address - Fax:
Practice Address - Street 1:40 N KINGSHIGHWAY BLVD APT 13F
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1343
Practice Address - Country:US
Practice Address - Phone:314-669-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013042707208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice