Provider Demographics
NPI:1336221548
Name:COHEN, ABBY (MD)
Entity type:Individual
Prefix:DR
First Name:ABBY
Middle Name:
Last Name:COHEN
Suffix:
Gender:M
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 7530
Mailing Address - Street 2:2155 SOUTH AVE #25-A
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158
Mailing Address - Country:US
Mailing Address - Phone:530-541-3286
Mailing Address - Fax:530-541-2005
Practice Address - Street 1:2155 SOUTH AVE
Practice Address - Street 2:#25-A
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96158
Practice Address - Country:US
Practice Address - Phone:530-541-3286
Practice Address - Fax:530-541-2005
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A43559Medicare UPIN