Provider Demographics
NPI:1619929239
Name:COHEN, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
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 1:11150 CASHMERE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-3203
Mailing Address - Country:US
Mailing Address - Phone:310-472-2267
Mailing Address - Fax:310-476-9416
Practice Address - Street 1:11150 CASHMERE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3203
Practice Address - Country:US
Practice Address - Phone:310-472-2267
Practice Address - Fax:310-476-9416
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG206182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G206180Medicaid
CA00G206180OtherBLUE SHIELD
CAWG20618NMedicare PIN
CAWG206180Medicare PIN
WG206180Medicare ID - Type Unspecified
CAP00264969Medicare PIN
CA00G206180Medicaid