Provider Demographics
NPI:1558466235
Name:COOPER-MERCHANT, EUGENIA GAINZEO (MD)
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:GAINZEO
Last Name:COOPER-MERCHANT
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 1:100 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9260
Mailing Address - Country:US
Mailing Address - Phone:843-234-0005
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9260
Practice Address - Country:US
Practice Address - Phone:843-234-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC129195Medicaid
SC129195Medicaid
BC6061460OtherDEA NUMBER