Provider Demographics
NPI:1841290319
Name:COOPER, WESLEY D (OD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:D
Last Name:COOPER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5738
Mailing Address - Country:US
Mailing Address - Phone:970-249-3914
Mailing Address - Fax:970-249-7893
Practice Address - Street 1:400 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5738
Practice Address - Country:US
Practice Address - Phone:970-249-3914
Practice Address - Fax:970-249-7893
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841290319OtherNPI
CO08765232Medicaid
COT60729Medicare UPIN
COC804455Medicare PIN
CO08765232Medicaid