Healthcare Provider Details

I. General information

NPI: 1245262690
Provider Name (Legal Business Name): LARRY L COHEN MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CALLE DE VALLE
SANTA FE NM
87505-6318
US

IV. Provider business mailing address

9 CALLE DE VALLE
SANTA FE NM
87505-6318
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-3997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number73-11
License Number StateNM

VIII. Authorized Official

Name: DR. LARRY COHEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-983-3997