Provider Demographics
NPI:1952365199
Name:COOPER, SHELBY S (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:S
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-547-3474
Mailing Address - Fax:607-547-6553
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3474
Practice Address - Fax:607-547-6553
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227885208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02391968Medicaid
NYDD5536Medicare ID - Type UnspecifiedUPSTATE
NY02391968Medicaid