Provider Demographics
NPI:1184695306
Name:COOPER, CEDRIC KENOD (DPM)
Entity type:Individual
Prefix:DR
First Name:CEDRIC
Middle Name:KENOD
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 1:647 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-2044
Mailing Address - Country:US
Mailing Address - Phone:731-635-4800
Mailing Address - Fax:731-635-4801
Practice Address - Street 1:647 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-2044
Practice Address - Country:US
Practice Address - Phone:731-635-4800
Practice Address - Fax:731-635-4801
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD0142213E00000X
TN332B00000X
TN628213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3353992Medicaid
TN3353992Medicaid
TNU95963Medicare UPIN
TN3353992Medicare ID - Type Unspecified