Provider Demographics
NPI:1851957609
Name:COOPER, DOUGLAS JUSTIN (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JUSTIN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-791-2000
Mailing Address - Fax:
Practice Address - Street 1:121 PARK PLACE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6690
Practice Address - Country:US
Practice Address - Phone:803-356-4712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
211D00000X
MN741213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric