Provider Demographics
NPI:1619958030
Name:COOLEY, BENJAMIN L (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:COOLEY
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 1:110 LIBERTY STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-565-0157
Practice Address - Street 1:110 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-565-0157
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2026929Medicaid
A53874Medicare UPIN
MA2026929Medicaid