Provider Demographics
NPI:1578830709
Name:COOLEY, BENJAMIN C (LMT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:COOLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2820
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-2820
Mailing Address - Country:US
Mailing Address - Phone:407-933-1500
Mailing Address - Fax:407-933-1503
Practice Address - Street 1:711 E OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4573
Practice Address - Country:US
Practice Address - Phone:407-933-1500
Practice Address - Fax:407-933-1503
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist