Basic Information
| Provider Information | |||||||||
| NPI: | 1427131762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SOUTHFIELD DR STE 1370 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461684300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178375566 | ||||||||
| FaxNumber: | 3178521246 | ||||||||
| Practice Location | |||||||||
| Address1: | 5492 N RONALD REAGAN PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | BROWNSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461125618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178523851 | ||||||||
| FaxNumber: | 3178521246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01047073 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200224060 | 05 | IN | MEDICAID |