Basic Information
Provider Information | |||||||||
NPI: | 1649677014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOPER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9787 | ||||||||
Address2: |   | ||||||||
City: | YAKIMA | ||||||||
State: | WA | ||||||||
PostalCode: | 989090787 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095758255 | ||||||||
FaxNumber: | 5095775056 | ||||||||
Practice Location | |||||||||
Address1: | 1200 N STATE ST CT-A7D | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 90033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3232267556 | ||||||||
FaxNumber: | 3232267556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2014 | ||||||||
LastUpdateDate: | 01/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 20A13699 | CA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 207P00000X | OP60919974 | WA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | JC3232267556 | 01 |   | INITIALS AND OFFICE PHONE NUMBER | OTHER |