Provider Demographics
NPI:1952491748
Name:COOPER, IVAN N (DPM, PC)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:N
Last Name:COOPER
Suffix:
Gender:M
Credentials:DPM, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 ALCOA HWY
Mailing Address - Street 2:SUITE C-480
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1527
Mailing Address - Country:US
Mailing Address - Phone:865-632-5700
Mailing Address - Fax:865-632-5778
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:SUITE C-480
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-632-5700
Practice Address - Fax:865-632-5778
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM132213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2008103OtherBLUE CROSS
TN3350481Medicaid
TN3350481Medicaid
TN3350481Medicare ID - Type Unspecified
TN0720960001Medicare NSC