Provider Demographics
NPI:1588640106
Name:COOPER, JONATHAN EDWARDS (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARDS
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 LEESOME LN
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12009-6307
Mailing Address - Country:US
Mailing Address - Phone:518-861-8021
Mailing Address - Fax:
Practice Address - Street 1:ST. PETER'S NURSING & REHAB. CENTER
Practice Address - Street 2:SOUTH MANNING BLVD. AND HACKETT BLVD.
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-8897
Practice Address - Country:US
Practice Address - Phone:518-525-1297
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
C59428Medicare UPIN