Provider Demographics
NPI:1982922365
Name:COOPER, JOSHUA BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BENJAMIN
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 1:770 PINE ST
Mailing Address - Street 2:SUITE 290
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2173
Mailing Address - Country:US
Mailing Address - Phone:478-743-1458
Mailing Address - Fax:478-755-1332
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:SUITE 290
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-743-1458
Practice Address - Fax:478-755-1332
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0776012085R0202X
AL31083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131722Medicaid
AL131725Medicaid
AL131724Medicaid