Provider Demographics
NPI:1780647453
Name:COHEN, JUSTIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
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 1:3415 MACCORKLE AVENUE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-8380
Mailing Address - Fax:304-388-8395
Practice Address - Street 1:3415 MACCORKLE AVENUE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-8380
Practice Address - Fax:304-388-8395
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19662207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
900002314OtherRAILROAD MEDICARE
WV0082381-000Medicaid
CO0864072Medicare PIN
900002314Medicare PIN
CO0864073Medicare PIN
900002314OtherRAILROAD MEDICARE