Provider Demographics
NPI:1275593956
Name:COHEN, MICHAEL IRA (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IRA
Last Name:COHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LIBERTY WAY
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:VA
Mailing Address - Zip Code:23314-2697
Mailing Address - Country:US
Mailing Address - Phone:910-728-7380
Mailing Address - Fax:
Practice Address - Street 1:650 JEFFERSON AVE
Practice Address - Street 2:MCDONALD ARMY HEALTH CENTER
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN