Healthcare Provider Details

I. General information

NPI: 1477517548
Provider Name (Legal Business Name): MIRIAM SUSAN COHEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: DR. MIRIAM SUSAN JENNINGS

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 04/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 BARNES RD STE 6
WALLINGFORD CT
06492-1885
US

IV. Provider business mailing address

195 BEAR PATH RD
HAMDEN CT
06514-1342
US

V. Phone/Fax

Practice location:
  • Phone: 203-753-6776
  • Fax: 203-573-1875
Mailing address:
  • Phone: 203-407-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number040590
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: