Healthcare Provider Details

I. General information

NPI: 1720065188
Provider Name (Legal Business Name): ERIC DAVID COHEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-4663
  • Fax: 575-624-4907
Mailing address:
  • Phone: 575-624-4663
  • Fax: 575-624-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32942
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number14308
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number32942
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD2019-0764
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD2019-0764
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: