Provider Demographics
NPI:1912179540
Name:COOPERMAN, RONALD S (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:S
Last Name:COOPERMAN
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 1:11999 SAN VICENTE BLVD STE 440
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5042
Mailing Address - Country:US
Mailing Address - Phone:310-471-5852
Mailing Address - Fax:
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-221-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14894207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G148940Medicaid
CAG14894AMedicare PIN
CAA90353Medicare UPIN