Healthcare Provider Details

I. General information

NPI: 1093711640
Provider Name (Legal Business Name): MICHAEL GARY COHEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4680 KING ST
ALEXANDRIA VA
22302-1215
US

IV. Provider business mailing address

9814 SUMMERDAY DR
BURKE VA
22015-4027
US

V. Phone/Fax

Practice location:
  • Phone: 703-845-1404
  • Fax: 703-845-5945
Mailing address:
  • Phone: 703-425-6851
  • Fax: 703-425-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000156
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618000156
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: