Provider Demographics
NPI:1558366310
Name:KOOPERMAN, SCOTT ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ELLIS
Last Name:KOOPERMAN
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 1:9312 DEER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2286
Mailing Address - Country:US
Mailing Address - Phone:813-575-9993
Mailing Address - Fax:813-575-9993
Practice Address - Street 1:9312 DEER CREEK DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2286
Practice Address - Country:US
Practice Address - Phone:813-575-9993
Practice Address - Fax:813-575-9993
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL110838207L00000X
KY30200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64030208Medicaid
0336304Medicare ID - Type Unspecified
KY64030208Medicaid