Provider Demographics
NPI:1669406104
Name:COOPER, RUSSELL WILLIAM (CTRS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:COOPER
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 BEL ABBES AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-1737
Mailing Address - Country:US
Mailing Address - Phone:541-779-1171
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist