Provider Demographics
NPI:1669427316
Name:COOPER, MELANIE L (MD)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 S ENOTA DR NE STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-8947
Mailing Address - Country:US
Mailing Address - Phone:470-290-8474
Mailing Address - Fax:770-593-9447
Practice Address - Street 1:578 S ENOTA DR NE STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-8947
Practice Address - Country:US
Practice Address - Phone:470-290-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045753207PE0005X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000800588KMedicaid
GAH00725Medicare UPIN