Provider Demographics
NPI:1568420107
Name:COOPER, VIDETTE V (MD)
Entity Type:Individual
Prefix:
First Name:VIDETTE
Middle Name:V
Last Name:COOPER
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 1:803 TILGHMAN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5509
Mailing Address - Country:US
Mailing Address - Phone:910-892-1091
Mailing Address - Fax:910-892-1097
Practice Address - Street 1:803 TILGHMAN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5509
Practice Address - Country:US
Practice Address - Phone:910-892-1091
Practice Address - Fax:910-892-1097
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909335Medicaid
SCGP4840OtherMEDICAID GROUP
SCT64356Medicaid
SC764356Medicaid
SCGP4306OtherMEDICAID GROUP
SCGP1883OtherMEDICAID GROUP
SCGP4306OtherMEDICAID GROUP
SCT64356Medicaid
NC5909335Medicaid
SCH322867153Medicare PIN