Provider Demographics
NPI:1619036951
Name:COOPER, ELLIS O III (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:O
Last Name:COOPER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1534 ELIZABETH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4531
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4644
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-635-3072
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-07-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA022842207XS0106X, 207XS0106X
NC200400476171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
4P036B103Medicare PIN