Provider Demographics
NPI:1831192574
Name:COOPER, LARRY J (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:COOPER
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 1:1001 W EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3745
Mailing Address - Country:US
Mailing Address - Phone:940-627-7443
Mailing Address - Fax:940-627-7597
Practice Address - Street 1:1001 W EAGLE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3745
Practice Address - Country:US
Practice Address - Phone:940-627-7443
Practice Address - Fax:940-627-7597
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD24002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136183401Medicaid
TX300067917OtherRAILROAD MEDICARE
TX160034488Medicaid
TXE10934Medicare UPIN
TX00J183Medicare PIN