Basic Information
| Provider Information | |||||||||
| NPI: | 1912179540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPERMAN | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD STE 440 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18321 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182210800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G14894 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G148940 | 05 | CA | MEDICAID |