Provider Demographics
NPI:1891782629
Name:LOOPER, MICHAEL R (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:LOOPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:827 FAIRMONT RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-3857
Mailing Address - Country:US
Mailing Address - Phone:304-296-3333
Mailing Address - Fax:304-296-2220
Practice Address - Street 1:827 FAIRMONT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-3857
Practice Address - Country:US
Practice Address - Phone:304-296-3333
Practice Address - Fax:304-296-2220
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV727-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150975000Medicaid
WV0150975000Medicaid
WV5439530001Medicare NSC
WV4140943Medicare PIN