Provider Demographics
NPI:1831691948
Name:COOPER, REESE JEREL (DO)
Entity type:Individual
Prefix:
First Name:REESE
Middle Name:JEREL
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1284
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:618-206-2332
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1284
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:618-206-2332
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7811204-2402225100000X
390200000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program