Provider Demographics
NPI:1730274457
Name:COOPER, JACK MEDFORD (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:MEDFORD
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 UPTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3529
Mailing Address - Country:US
Mailing Address - Phone:972-637-1300
Mailing Address - Fax:866-353-7586
Practice Address - Street 1:634 UPTOWN BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3529
Practice Address - Country:US
Practice Address - Phone:972-637-1300
Practice Address - Fax:866-353-7586
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2614207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
751622524OtherUNITED HEALTHCARE
TX86770XOtherBCBS PROVIDER ID
0612336OtherAETNA HMO
0612336OtherAETNA POS
TX0016DQOtherBCBS GROUP
TX112288904Medicaid
TX112288905Medicaid
TX2314758OtherBCBS BLUE LINK
TX180011221OtherMEDICARE RR DALLAS COUNTY
TX180032049OtherMEDICARE RR ELLIS COUNTY
4237247OtherAETNA PPO
0612336OtherAETNA HMO
4237247OtherAETNA PPO
TX180032049OtherMEDICARE RR ELLIS COUNTY
TX2314758OtherBCBS BLUE LINK