Provider Demographics
NPI:1629135561
Name:COOPERSMITH, RICHARD GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GARY
Last Name:COOPERSMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2358
Mailing Address - Country:US
Mailing Address - Phone:203-426-2490
Mailing Address - Fax:203-426-8631
Practice Address - Street 1:54 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2358
Practice Address - Country:US
Practice Address - Phone:203-426-2490
Practice Address - Fax:203-426-8631
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT205111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22383Medicare UPIN
CT35000452Medicare ID - Type Unspecified