Provider Demographics
NPI:1720065188
Name:COHEN, ERIC DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
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 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-624-4663
Mailing Address - Fax:575-624-4907
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-624-4663
Practice Address - Fax:575-624-4907
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32942207RC0000X, 207RI0011X
AL14308207RC0000X
NMMD2019-0764207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM859420OtherMEDICARE PTAN / ROSWELL CLINIC CORP
NM36970832Medicaid
AL009929395Medicaid
AZ337603Medicaid