Provider Demographics
NPI:1902895709
Name:COHEN, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:COHEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:4620 N STATE ROAD 7
Mailing Address - Street 2:SUITE 316
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5884
Mailing Address - Country:US
Mailing Address - Phone:954-967-6400
Mailing Address - Fax:954-967-6410
Practice Address - Street 1:400 N HIATUS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5214
Practice Address - Country:US
Practice Address - Phone:954-431-8000
Practice Address - Fax:954-436-0449
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
FLME36465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C07957Medicare UPIN