Provider Demographics
NPI:1942299151
Name:COOPER, JERRY D (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:D
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 1:2565 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7516
Mailing Address - Country:US
Mailing Address - Phone:208-523-2928
Mailing Address - Fax:208-523-2962
Practice Address - Street 1:2565 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7516
Practice Address - Country:US
Practice Address - Phone:208-523-2928
Practice Address - Fax:208-523-2962
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP126213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001393600Medicaid
ID001393600Medicaid
ID0283120001Medicare NSC