Provider Demographics
NPI:1942368568
Name:COOPER, MARTIN (PHD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 COLERIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4122
Mailing Address - Country:US
Mailing Address - Phone:718-934-8208
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTY ROAD 516
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-1421
Practice Address - Country:US
Practice Address - Phone:732-254-8200
Practice Address - Fax:732-613-0017
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100214700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0435007Medicaid
NJ400780Medicare ID - Type Unspecified