Provider Demographics
NPI:1740229939
Name:COOPER, JOHN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
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 1:1210 KY HIGHWAY 36 E
Mailing Address - Street 2:SUITE 2 C
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7490
Mailing Address - Country:US
Mailing Address - Phone:859-234-6000
Mailing Address - Fax:859-234-6011
Practice Address - Street 1:1210 KY HIGHWAY 36 E
Practice Address - Street 2:SUITE 2 C
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-6000
Practice Address - Fax:859-234-6011
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64211956Medicaid
KY1049879OtherAETNA
KY000000041815OtherANTHEM
KY0399601Medicare ID - Type Unspecified
KY000000041815OtherANTHEM