Provider Demographics
NPI:1750467189
Name:COOPER, STEPHANIE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:COOPER VASTOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:160 CROSSWAYS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2028
Mailing Address - Country:US
Mailing Address - Phone:516-364-4200
Mailing Address - Fax:516-590-0267
Practice Address - Street 1:160 CROSSWAYS PARK DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2028
Practice Address - Country:US
Practice Address - Phone:516-364-4200
Practice Address - Fax:516-590-0267
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1761492086S0122X
NY176149-01208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1750467189OtherNPI
05854OtherMEDICARE
P640524OtherOXFORD
F71916Medicare UPIN