Basic Information
| Provider Information | |||||||||
| NPI: | 1609924273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOPER | ||||||||
| OtherFirstName: | BEN | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 208 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284757244 | ||||||||
| FaxNumber: | 9284757370 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 SENECA LN | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284757244 | ||||||||
| FaxNumber: | 9284757370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1795 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2003002705 | MO | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 185037 | 05 | AZ | MEDICAID |