Provider Demographics
NPI:1811959612
Name:COONEY, DEREK ROBERT (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ROBERT
Last Name:COONEY
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 1:750 E ADAMS ST
Mailing Address - Street 2:UPSTATE EMERGENCY MEDICINE
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4363
Mailing Address - Fax:315-464-8690
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:UPSTATE EMERGENCY MEDICINE
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-4363
Practice Address - Fax:315-464-8690
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0691207P00000X
NY243861207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1721391-01Medicaid
TX8P9119OtherBLUE SHIELD
NY02881712Medicaid
TX1721391-02OtherCSHCN
NY02881712Medicaid
NYRB4693Medicare PIN