Provider Demographics
NPI:1619998465
Name:COOPER, PAUL DANNER (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DANNER
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 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-8600
Mailing Address - Fax:318-675-8638
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-8600
Practice Address - Fax:318-675-8638
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023609208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486621Medicaid
LAH46508Medicare UPIN
LA1486621Medicaid