Provider Demographics
NPI:1649266602
Name:COHEN, MARK B (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:COHEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4034 SILVER CHARM CT
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1480
Mailing Address - Country:US
Mailing Address - Phone:717-319-2089
Mailing Address - Fax:
Practice Address - Street 1:4854 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5207
Practice Address - Country:US
Practice Address - Phone:717-657-3682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2025-01-30
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
PAOEG 41152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA035503Medicare PIN
PA0152040002Medicare NSC
T27242Medicare UPIN