Provider Demographics
NPI:1881681666
Name:COOPER, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCKENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:136 S WILSON ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1133
Practice Address - Country:US
Practice Address - Phone:731-364-4900
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN29115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICAID GROUP
TN29115OtherMD LLICENSE
TN1509513Medicaid
TN38241821OtherMEDICARE PTAN
TN3380640OtherMEDICARE GROUP
TN3380640OtherMEDICARE GROUP