Provider Demographics
NPI:1487655965
Name:COHEN, EZRA M (OD)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:M
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 1:372 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4018
Mailing Address - Country:US
Mailing Address - Phone:718-946-5060
Mailing Address - Fax:718-946-5161
Practice Address - Street 1:372 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4018
Practice Address - Country:US
Practice Address - Phone:718-946-5060
Practice Address - Fax:718-946-5161
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003854-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00503255Medicaid
NYC27871Medicare ID - Type Unspecified
NY00503255Medicaid