Provider Demographics
NPI:1609287846
Name:MERVYN-COHEN, VANESSA JOY (DO)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JOY
Last Name:MERVYN-COHEN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:MERVYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 LEWIS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2108
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:888-539-8781
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18775204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04907228Medicaid