Provider Demographics
NPI:1144515818
Name:COHEN, EZRA M (MD)
Entity type:Individual
Prefix:
First Name:EZRA
Middle Name:M
Last Name:COHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVENUE, YACC 6
Practice Address - Street 2:PEDIATRIC PRIMARY CARE & ADOLESCENT CLINIC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2583822080P0216X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110100633AMedicaid