Provider Demographics
NPI:1558341891
Name:COOPER, JAY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:M
Last Name:COOPER
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 667
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-0667
Mailing Address - Country:US
Mailing Address - Phone:831-385-1280
Mailing Address - Fax:831-385-1285
Practice Address - Street 1:300 CANAL ST
Practice Address - Street 2:SUITE B
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3431
Practice Address - Country:US
Practice Address - Phone:831-385-1280
Practice Address - Fax:831-385-1285
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69042207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A690420OtherBLUE SHIELD PIN
CA00A690420Medicaid
9416832OtherPHCS
CA00A690422Medicare PIN
P00267521Medicare PIN
CAB0214YMedicare PIN
CA00A690420Medicaid