Provider Demographics
NPI:1457571630
Name:COOPER, EVERETT CORDIE III (MD)
Entity Type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:CORDIE
Last Name:COOPER
Suffix:III
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 1:468 INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2834
Mailing Address - Country:US
Mailing Address - Phone:321-783-1236
Mailing Address - Fax:
Practice Address - Street 1:CHS-005
Practice Address - Street 2:
Practice Address - City:KENNEDY SPACE CENTER
Practice Address - State:FL
Practice Address - Zip Code:32899
Practice Address - Country:US
Practice Address - Phone:321-861-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46394207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine