Basic Information
| Provider Information | |||||||||
| NPI: | 1629056734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | BRENDON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 CLOVERLEAF AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782093818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108242246 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109163955 | ||||||||
| FaxNumber: | 2109164040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 32263 | TX | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.