Provider Demographics
NPI:1912944133
Name:COHEN, IAN D (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:D
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 1:800 N WESTMORELAND ROAD SUITE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1673
Mailing Address - Country:US
Mailing Address - Phone:847-735-8550
Mailing Address - Fax:847-582-2198
Practice Address - Street 1:800 N WESTMORELAND ROAD SUITE 102
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-735-8550
Practice Address - Fax:847-582-2198
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086745207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5931543OtherAETNA
ILF35228Medicare UPIN