Provider Demographics
NPI:1063575884
Name:COHEN, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:COHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 RITA DR
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 SENECA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2895
Practice Address - Country:US
Practice Address - Phone:718-366-4546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006583-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05893Medicare ID - Type Unspecified