Provider Demographics
NPI:1770556516
Name:COOPER, THOMAS W (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-533-1491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6992207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010064699OtherMEDICARE RAILROAD
TX123038OtherCHIPS
TX752616977015OtherTRICARE
TX752616977010OtherTRICARE
TX4380144OtherAETNA
TX141088801Medicaid
TX752616977009OtherTRICARE CHAMPUS
TXCO088865GOtherBCBS
TX752616977015OtherTRICARE
TX752616977010OtherTRICARE
TX8543M3Medicare ID - Type Unspecified