Provider Demographics
NPI:1366474462
Name:COHEN, CAROLE BLACK (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:BLACK
Last Name:COHEN
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 1:10 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1499
Mailing Address - Country:US
Mailing Address - Phone:860-676-6670
Mailing Address - Fax:860-675-5619
Practice Address - Street 1:10 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1499
Practice Address - Country:US
Practice Address - Phone:860-676-7760
Practice Address - Fax:860-675-5619
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0331392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260003196Medicare ID - Type Unspecified
CTF67263Medicare UPIN