Provider Demographics
NPI:1578590683
Name:COHEN, ELLIOTT LEE (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:LEE
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 1:1802 LEEDS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3576
Mailing Address - Country:US
Mailing Address - Phone:817-421-5007
Mailing Address - Fax:
Practice Address - Street 1:201 WALLS DR
Practice Address - Street 2:WALLS REGIONAL
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4007
Practice Address - Country:US
Practice Address - Phone:817-641-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6328207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161179008Medicaid
TX8D4505Medicare PIN
TX161179008Medicaid