Provider Demographics
NPI:1801897129
Name:COOPERBERG, DAVID B (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:COOPERBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12265 TOWNSEND RD
Mailing Address - Street 2:STE 500
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1201
Mailing Address - Country:US
Mailing Address - Phone:215-856-1014
Mailing Address - Fax:215-853-1020
Practice Address - Street 1:1648 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-938-2748
Practice Address - Fax:215-938-2966
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 071129L2080I0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018437590001Medicaid
PA0018437590001Medicaid