Basic Information
| Provider Information | |||||||||
| NPI: | 1568551414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | O. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 207 N TOWNLINE RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467611325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604639470 | ||||||||
| FaxNumber: | 2606657312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 01021456 | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 01021456A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100408010 | 05 | IN | MEDICAID |