Provider Demographics
NPI:1740288687
Name:COOPER, WARREN L (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:L
Last Name:COOPER
Suffix:
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 1:216 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3018
Mailing Address - Country:US
Mailing Address - Phone:740-236-2166
Mailing Address - Fax:
Practice Address - Street 1:410 2ND ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2115
Practice Address - Country:US
Practice Address - Phone:740-374-3622
Practice Address - Fax:740-374-4209
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.052253207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0091619000Medicaid
OH0593406Medicaid
WV6200090Medicaid
OHP01353055OtherRAILROAD MEDICARE - MHCPI
WV0091619000Medicaid
WV9371911Medicare PIN
OHP01353055OtherRAILROAD MEDICARE - MHCPI
C00577211Medicare ID - Type Unspecified