Provider Demographics
NPI:1104826213
Name:COHEN, HARTLEY (MD)
Entity Type:Individual
Prefix:
First Name:HARTLEY
Middle Name:
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 1:15581 WILD PLUM CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2954
Mailing Address - Country:US
Mailing Address - Phone:213-977-1010
Mailing Address - Fax:213-977-1239
Practice Address - Street 1:637 LUCAS AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1997
Practice Address - Country:US
Practice Address - Phone:213-977-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31532207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A315320Medicaid
CA00A315320OtherBLUE SHIELD PIN
CACB209349OtherMEDICARE
CACB209349OtherMEDICARE