Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | PENDING | IL |
Y | 208600000X | Surgeon | PENDING | IL |
NPI | 1013208958 |
---|---|
Provider Name | Moungar Elton Cooper |
First Address | Centreville, IL 62207-2326 |
Second Address | Centreville, IL 62207-2326 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2011 |
Last Update Date | 18/12/2018 |