Provider Demographics
NPI:1699740886
Name:COHEN, RICHARD SHALETT (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SHALETT
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 1:52 UTICA ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 UTICA ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-1108
Practice Address - Country:US
Practice Address - Phone:315-824-2477
Practice Address - Fax:315-824-1851
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00572909Medicaid
NY00572909Medicaid
NY53143AMedicare ID - Type Unspecified