Provider Demographics
NPI:1609924273
Name:COOPER, BENJAMIN D (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:D
Last Name:COOPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:MR
Other - First Name:BEN
Other - Middle Name:D
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-7244
Mailing Address - Fax:928-475-7370
Practice Address - Street 1:223 SENECA LN
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-7244
Practice Address - Fax:928-475-7370
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1795152W00000X
MO2003002705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ185037Medicaid
AZ8HG092Medicare PIN
AZ185037Medicaid
AZ8HG093Medicare PIN