Provider Demographics
NPI:1477505063
Name:COOPER, KEITH E (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1239
Mailing Address - Country:US
Mailing Address - Phone:608-825-3500
Mailing Address - Fax:608-825-3676
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3500
Practice Address - Fax:608-825-3676
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65886-21207Q00000X, 207R00000X
IN02002249A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477505063Medicaid
IN190040Medicare ID - Type Unspecified