Provider Demographics
NPI:1023078037
Name:COOPER, WILLIAM R (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:COOPER
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 1:1185 CORPORATE CENTER DR STE 175
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4889
Mailing Address - Country:US
Mailing Address - Phone:262-928-8400
Mailing Address - Fax:
Practice Address - Street 1:1185 CORPORATE CENTER DR STE 175
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4889
Practice Address - Country:US
Practice Address - Phone:262-928-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328213900Medicaid
683750581Medicare PIN
110003670Medicare ID - Type Unspecified
MN328213900Medicaid