Provider Demographics
NPI:1992744163
Name:COHEN, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
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 1:1619 N GREENWOOD ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2644
Mailing Address - Country:US
Mailing Address - Phone:719-595-7760
Mailing Address - Fax:719-595-7765
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 402
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-595-7760
Practice Address - Fax:719-595-7765
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO436592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76657787Medicaid
COC803666Medicare PIN
CO76657787Medicaid