Provider Demographics
NPI:1396728598
Name:COOPER, JERRY DEWAYNE (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DEWAYNE
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 1:275 COLLIER RD NW
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1709
Mailing Address - Country:US
Mailing Address - Phone:404-352-3300
Mailing Address - Fax:404-352-9453
Practice Address - Street 1:275 COLLIER RD NW
Practice Address - Street 2:SUITE 290
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1709
Practice Address - Country:US
Practice Address - Phone:404-352-3300
Practice Address - Fax:404-352-9453
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013262207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00134142GMedicaid
GA39BDCCCMedicare ID - Type Unspecified
GA00134142GMedicaid