Provider Demographics
NPI:1801896014
Name:COOPER, MARK W (DO)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1103 VILLAGE SQUARE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1783
Mailing Address - Country:US
Mailing Address - Phone:419-874-8745
Mailing Address - Fax:419-874-8748
Practice Address - Street 1:1103 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1783
Practice Address - Country:US
Practice Address - Phone:419-874-8745
Practice Address - Fax:419-874-8748
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH3895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0608631Medicaid
C00575954Medicare ID - Type Unspecified
OH0608631Medicaid