Provider Demographics
NPI:1578627410
Name:COOPER, EZRA ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:ROBERT
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 1:108 COLD SPRING RD
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3110
Mailing Address - Country:US
Mailing Address - Phone:516-364-1465
Mailing Address - Fax:516-364-1465
Practice Address - Street 1:108 COLD SPRING RD
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3110
Practice Address - Country:US
Practice Address - Phone:516-364-1465
Practice Address - Fax:516-364-1465
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003441-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX20181Medicare ID - Type Unspecified