Provider Demographics
NPI:1700985736
Name:COONER, EDWARD W
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:W
Last Name:COONER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GROVE RD
Mailing Address - Street 2:PO BOX 37
Mailing Address - City:THOROFARE
Mailing Address - State:NJ
Mailing Address - Zip Code:08086-0037
Mailing Address - Country:US
Mailing Address - Phone:856-845-8010
Mailing Address - Fax:856-845-9398
Practice Address - Street 1:400 GROVE RD
Practice Address - Street 2:
Practice Address - City:THOROFARE
Practice Address - State:NJ
Practice Address - Zip Code:08086-0037
Practice Address - Country:US
Practice Address - Phone:856-845-8010
Practice Address - Fax:856-845-9398
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA6550700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7259204Medicaid
G47972Medicare UPIN
C0902490Medicare ID - Type Unspecified