Provider Demographics
NPI:1780657155
Name:COOPER, COLLIN E (MD)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:E
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 1:1818 VERDUGO BLVD
Mailing Address - Street 2:108
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1403
Mailing Address - Country:US
Mailing Address - Phone:818-790-1145
Mailing Address - Fax:818-790-6287
Practice Address - Street 1:1818 VERDUGO BLVD
Practice Address - Street 2:108
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1403
Practice Address - Country:US
Practice Address - Phone:818-790-1145
Practice Address - Fax:818-790-6287
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C36133Medicare UPIN