Provider Demographics
NPI:1790912608
Name:COOPRIDER, BRIAN DAVID (IDMT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:COOPRIDER
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART ROAD
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:68113-2160
Mailing Address - Country:US
Mailing Address - Phone:402-294-7333
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART ROAD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68113-2160
Practice Address - Country:US
Practice Address - Phone:402-294-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians