Provider Demographics
NPI:1821032012
Name:COOPER, JOHN TAYLOR (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TAYLOR
Last Name:COOPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ELIZABETH PL
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-1918
Mailing Address - Country:US
Mailing Address - Phone:251-391-0375
Mailing Address - Fax:
Practice Address - Street 1:212 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-2448
Practice Address - Country:US
Practice Address - Phone:251-368-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL S-651-TA-315152W00000X
FLOPC 2443152W00000X
MS702152W00000X
GA1269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69167Medicare UPIN