Provider Demographics
NPI:1477517548
Name:COHEN, MIRIAM SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:SUSAN
Last Name:COHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MIRIAM
Other - Middle Name:SUSAN
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:195 BEAR PATH RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-1342
Mailing Address - Country:US
Mailing Address - Phone:203-407-0161
Mailing Address - Fax:
Practice Address - Street 1:97 BARNES RD
Practice Address - Street 2:STE 6
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1885
Practice Address - Country:US
Practice Address - Phone:203-753-6776
Practice Address - Fax:203-573-1875
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040590208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001405902Medicaid
CT001405902Medicaid
CTH73157Medicare UPIN