Provider Demographics
NPI:1689103798
Name:COOPER, CRYSTAL (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24911 LITTLE MACK AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3200
Mailing Address - Country:US
Mailing Address - Phone:586-777-2050
Mailing Address - Fax:586-777-2189
Practice Address - Street 1:24911 LITTLE MACK AVE STE C
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3200
Practice Address - Country:US
Practice Address - Phone:586-777-2050
Practice Address - Fax:586-777-2189
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036153220207P00000X
MI4301112029207Q00000X
MIEMC0001216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine