Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 05774 | MS |
NPI | 1013013648 |
---|---|
Provider Name | Dr. Tom Cooper |
First Address | Clarksdale, MS 38614-6733 |
Second Address | Clarksdale, MS 38614-6733 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00115320 | (05) | MS |
B30729 | (02) |