Healthcare Provider Details

I. General information

NPI: 1013140177
Provider Name (Legal Business Name): ABBY COHEN MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 SOUTH AVE SUITE B
SOUTH LAKE TAHOE CA
96150-7037
US

IV. Provider business mailing address

PO BOX 7530
SOUTH LAKE TAHOE CA
96158-0530
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-3286
  • Fax: 530-541-2005
Mailing address:
  • Phone: 530-541-3286
  • Fax: 530-541-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG27971
License Number StateCA

VIII. Authorized Official

Name: DR. ABBY COHEN
Title or Position: CEO
Credential: M.D.
Phone: 530-541-3286