Provider Demographics
NPI:1760512040
Name:COHEN, GAVIN
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:COHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 W PACES FERRY RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2306
Mailing Address - Country:US
Mailing Address - Phone:404-844-1500
Mailing Address - Fax:404-844-2700
Practice Address - Street 1:1244 W PACES FERRY RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2306
Practice Address - Country:US
Practice Address - Phone:404-844-1500
Practice Address - Fax:404-844-2700
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1768152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV00395Medicare UPIN