Basic Information
| Provider Information | |||||||||
| NPI: | 1821275900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043983262 | ||||||||
| FaxNumber: | 9042656407 | ||||||||
| Practice Location | |||||||||
| Address1: | 14540 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 2207 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322587418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046520800 | ||||||||
| FaxNumber: | 9046520811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME109775 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 003837100 | 05 | FL | MEDICAID |