Provider Demographics
NPI:1790771160
Name:COOPERRIDER, TERESA T (OD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:T
Last Name:COOPERRIDER
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 1:637 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44842-1074
Mailing Address - Country:US
Mailing Address - Phone:419-994-4287
Mailing Address - Fax:419-994-2612
Practice Address - Street 1:637 N UNION ST
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-1074
Practice Address - Country:US
Practice Address - Phone:419-994-4287
Practice Address - Fax:419-994-2612
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4055/T215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893323Medicaid
OH0627083Medicare PIN
OH0627084Medicare PIN
OHU08689Medicare UPIN
OH0893323Medicaid
OH0780800001Medicare NSC