Provider Demographics
NPI:1205836947
Name:COHEN, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
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:
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Mailing Address - Street 1:11516 183RD PL STE SW
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9471
Mailing Address - Country:US
Mailing Address - Phone:708-877-1300
Mailing Address - Fax:708-596-8719
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:STE 400
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4265
Practice Address - Country:US
Practice Address - Phone:708-596-8710
Practice Address - Fax:708-596-9820
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088028207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180033410OtherRRMC
IL036088028Medicaid
F81606Medicare UPIN
ILL37826Medicare PIN