Healthcare Provider Details

I. General information

NPI: 1245074061
Provider Name (Legal Business Name): SAMANTHA COHEN, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4036 3RD AVE STE 210
SAN DIEGO CA
92103-2102
US

IV. Provider business mailing address

1612 32ND ST
SAN DIEGO CA
92102-1608
US

V. Phone/Fax

Practice location:
  • Phone: 626-825-0927
  • Fax: 626-314-5242
Mailing address:
  • Phone: 619-320-8696
  • Fax: 626-314-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA COHEN
Title or Position: CEO/DEVELOPMENTAL BEHAVIORAL PED.
Credential: MD
Phone: 619-320-8696