Provider Demographics
NPI:1558491621
Name:COOPER, GARY KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:KEITH
Last Name:COOPER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 HARRY L DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1606
Mailing Address - Country:US
Mailing Address - Phone:607-798-0356
Mailing Address - Fax:607-798-0164
Practice Address - Street 1:89 HARRY L DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1606
Practice Address - Country:US
Practice Address - Phone:607-798-0356
Practice Address - Fax:607-798-0164
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011436-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB5529Medicare PIN