Basic Information
| Provider Information | |||||||||
| NPI: | 1700959145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | CONRAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 MANORHAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110501627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168837100 | ||||||||
| FaxNumber: | 5168837474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101281235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129968270 | ||||||||
| FaxNumber: | 2128316185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 097115 | NY | Y | Other Service Providers | Specialist |
No ID Information.