Healthcare Provider Details

I. General information

NPI: 1144515818
Provider Name (Legal Business Name): EZRA M. COHEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVENUE, YACC 6 PEDIATRIC PRIMARY CARE & ADOLESCENT CLINIC
BOSTON MA
02118
US

IV. Provider business mailing address

720 HARRISON AVE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number258382
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number258382
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: