Provider Demographics
NPI:1760644124
Name:COHEN, LISA BROOKE (DPM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BROOKE
Last Name:COHEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3822
Mailing Address - Country:US
Mailing Address - Phone:773-282-3377
Mailing Address - Fax:773-205-4439
Practice Address - Street 1:5012 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3822
Practice Address - Country:US
Practice Address - Phone:773-282-3377
Practice Address - Fax:773-205-4439
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005305213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01600112OtherBCBS
ILIL2629001Medicare PIN