Basic Information
| Provider Information | |||||||||
| NPI: | 1649299090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11100 EUCLID AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168448200 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 35-068611 | OH | N | Allopathic & Osteopathic Physicians | Dermatology | 207NI0002X | 35-068611 | OH | Y | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology |
ID Information
| ID | Type | State | Issuer | Description | 742206 | 01 | BUCKEYE | OTHER | 0019479400002 | 05 | PA | MEDICAID | 000000523162 | 01 | OH | ANTHEM | OTHER | 70013591 | 01 | OH | RAILROAD MEDICARE | OTHER | 1049435 | 01 | OH | AETNA | OTHER | 000000140401 | 01 | OH | ANTHEM | OTHER | 000000221135 | 01 | UNISON | OTHER | 0161908 | 05 | OH | MEDICAID | 363444 | 01 | WELLCARE | OTHER |