Provider Demographics
NPI:1811989890
Name:COOPER, RAPHAEL M (MD)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:279 NEW BRITAIN RD
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1353
Mailing Address - Country:US
Mailing Address - Phone:860-828-9700
Mailing Address - Fax:860-828-9737
Practice Address - Street 1:279 NEW BRITAIN RD
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1353
Practice Address - Country:US
Practice Address - Phone:860-828-9700
Practice Address - Fax:860-828-9737
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027530208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001275305Medicaid
CTE48411Medicare UPIN
CT001275305Medicaid