Provider Demographics
NPI:1780844886
Name:COOPER, TARA JALAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:JALAYNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-5525
Mailing Address - Country:US
Mailing Address - Phone:641-752-5700
Mailing Address - Fax:
Practice Address - Street 1:400 BROWN RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1305
Practice Address - Country:US
Practice Address - Phone:248-648-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002435152W00000X
MI4901005105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1780844886Medicaid
IA1780844886OtherBLUE CROSS BLUE SHIELD
IA1780844886OtherBLUE CROSS BLUE SHIELD