Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 14854 | MS |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 14854 | MS |
NPI | 1407887797 |
---|---|
Provider Name | Cooper Loomis Terry |
First Address | Oxford, MS 38655-7905 |
Second Address | Oxford, MS 38655-7905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 10/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00117049 | (05) | MS |
G03967 | (02) | MS |