Provider Demographics
NPI:1811975667
Name:COOPER, RANDALL ALLEN (DPM)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALLEN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 E BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3968
Mailing Address - Country:US
Mailing Address - Phone:574-264-7180
Mailing Address - Fax:574-264-1875
Practice Address - Street 1:1723 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3968
Practice Address - Country:US
Practice Address - Phone:574-264-7180
Practice Address - Fax:574-264-1875
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000384A213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112180Medicaid
IN480010783OtherPALMETTO GBA-RAILROAD MEDICARE
IN100112180Medicaid
IN0228850001Medicare NSC
INT34636Medicare UPIN