Provider Demographics
NPI:1902003379
Name:DR THERESA ANN COOPER PC
Entity Type:Organization
Organization Name:DR THERESA ANN COOPER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVEENE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-299-9779
Mailing Address - Street 1:10131 S. YALE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137
Mailing Address - Country:US
Mailing Address - Phone:918-299-9779
Mailing Address - Fax:918-477-2779
Practice Address - Street 1:10131 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137
Practice Address - Country:US
Practice Address - Phone:918-299-9779
Practice Address - Fax:918-477-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG37041Medicare UPIN