Provider Demographics
NPI:1790848299
Name:SCHRAUDENBACH, COOPER C (MD)
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:C
Last Name:SCHRAUDENBACH
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 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9400
Mailing Address - Fax:928-774-4808
Practice Address - Street 1:1 CLINIC RD
Practice Address - Street 2:
Practice Address - City:GRAND CANYON
Practice Address - State:AZ
Practice Address - Zip Code:86023-0290
Practice Address - Country:US
Practice Address - Phone:928-638-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP0348207Q00000X
CAA067909207Q00000X
AZ45923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA67909OtherLICENSE
MP0348OtherLICENSE
HI12456OtherLIC
CABS6245369OtherDEA