Provider Demographics
NPI:1851395602
Name:COOPER, GEORGE LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:LEONARD
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 1:2139 VALLEYGATE DR
Mailing Address - Street 2:STE 101A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3666
Mailing Address - Country:US
Mailing Address - Phone:910-323-2002
Mailing Address - Fax:910-323-3477
Practice Address - Street 1:2139 VALLEYGATE DR
Practice Address - Street 2:STE 101A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3666
Practice Address - Country:US
Practice Address - Phone:910-323-2002
Practice Address - Fax:910-323-3477
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600893207W00000X
NY1925301207W00000X
KY31520207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0838866OtherUHC PROVIDER NUMBER
NC1083NOtherBC/BS PROVIDER NUMBER
NC891083NMedicaid
NCG11691Medicare UPIN
NC1083NOtherBC/BS PROVIDER NUMBER