Provider Demographics
NPI:1912168915
Name:COOPER, MATTHEW LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LAWRENCE
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 1:793 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1551
Mailing Address - Country:US
Mailing Address - Phone:614-234-5000
Mailing Address - Fax:
Practice Address - Street 1:714 N SENATE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3763
Practice Address - Country:US
Practice Address - Phone:317-715-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57014227207X00000X
IN01072622A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201178370Medicaid
IN959090005Medicare PIN
IN201178370Medicaid