Provider Demographics
NPI:1801895602
Name:COOPER, LAWRENCE RICHARD (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:RICHARD
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 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-546-2188
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:300
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-546-2180
Practice Address - Fax:707-546-2188
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G813930Medicaid
CA00G813930OtherBLUE SHIELD OF CALIFORNIA
CA110180276OtherRAILROAD MEDICARE
CAFA089ZMedicare PIN
CAG48255Medicare UPIN
CA00G813931Medicare PIN
CA00G813932Medicare PIN