Provider Demographics
NPI:1174718480
Name:KOOPER, DIANA CONSTANZA (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:CONSTANZA
Last Name:KOOPER
Suffix:
Gender:F
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:PO BOX 112019
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-0134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:239-624-0464
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-624-3997
Practice Address - Fax:239-624-8101
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259408208M00000X, 207R00000X
TN48309208M00000X, 207R00000X
FLME104136208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116356800Medicaid
TN1527585Medicaid
VA1174718480Medicaid
TN6005996OtherBCBST
VAVVJ419AMedicare PIN