Provider Demographics
NPI:1760487425
Name:COOPER, JAC ALAN SR (MD)
Entity Type:Individual
Prefix:
First Name:JAC
Middle Name:ALAN
Last Name:COOPER
Suffix:SR
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:85 E US HIGHWAY 6 STE 240
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-983-6240
Practice Address - Fax:219-983-6040
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035869A2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100207020Medicaid
IN000000082449OtherANTHEM
653940EMedicare ID - Type UnspecifiedMEDICARE PRIMARY LOCATION
IN100207020Medicaid
655280EMedicare ID - Type UnspecifiedMEDICARE SECONDARY LOCATI