Provider Demographics
NPI:1356348676
Name:COOPER, KENNETH LEE JR (DPM)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:COOPER
Suffix:JR
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 1:832 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43793-1093
Mailing Address - Country:US
Mailing Address - Phone:740-472-2259
Mailing Address - Fax:740-472-5836
Practice Address - Street 1:832 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:WOODSFIELD
Practice Address - State:OH
Practice Address - Zip Code:43793-1093
Practice Address - Country:US
Practice Address - Phone:740-472-2259
Practice Address - Fax:740-472-5836
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003239213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2328243Medicaid
OH4600520001Medicare PIN
OH4081101Medicare PIN
OH2328243Medicaid