Healthcare Provider Details

I. General information

NPI: 1285809012
Provider Name (Legal Business Name): STANLEY A COHEN DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 PALENCIA CLUB DR # 201
ST AUGUSTINE FL
32095-6901
US

IV. Provider business mailing address

605 PALENCIA CLUB DR # 201
ST AUGUSTINE FL
32095-6901
US

V. Phone/Fax

Practice location:
  • Phone: 904-808-8595
  • Fax: 904-808-8596
Mailing address:
  • Phone: 904-808-8595
  • Fax: 904-808-8596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS7389
License Number StateFL

VIII. Authorized Official

Name: SHANAN MOORE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 904-808-8595