Provider Demographics
NPI:1760567242
Name:COHEN, IVAN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:MICHAEL
Last Name:COHEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10695 NORTHGREEN DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33467-8048
Mailing Address - Country:US
Mailing Address - Phone:561-868-5544
Mailing Address - Fax:
Practice Address - Street 1:141 S MAIN ST
Practice Address - Street 2:SUITE 151
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-3445
Practice Address - Country:US
Practice Address - Phone:561-996-9936
Practice Address - Fax:561-996-9934
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7024111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0403035OtherFL WORKMANS COMP
FL55433OtherBC/BS FL
FL55433OtherBC/BS FL