Provider Demographics
NPI:1093711640
Name:COHEN, MICHAEL GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARY
Last Name:COHEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9814 SUMMERDAY DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4027
Mailing Address - Country:US
Mailing Address - Phone:703-425-6851
Mailing Address - Fax:703-425-3560
Practice Address - Street 1:4680 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1215
Practice Address - Country:US
Practice Address - Phone:703-845-1404
Practice Address - Fax:703-845-5945
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000156152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21379Medicare UPIN
VAC0424614Medicare ID - Type Unspecified