Provider Demographics
NPI:1619049459
Name:COOPER, AMANDA S (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:NORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8100 RAVINES EDGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5426
Mailing Address - Country:US
Mailing Address - Phone:614-488-5090
Mailing Address - Fax:614-845-5216
Practice Address - Street 1:8100 RAVINES EDGE CT STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5426
Practice Address - Country:US
Practice Address - Phone:614-488-5090
Practice Address - Fax:614-845-5216
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0902942085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00418673OtherRR MEDICARE
OH4213771Medicare PIN
OHG29936Medicare UPIN