Healthcare Provider Details

I. General information

NPI: 1063461556
Provider Name (Legal Business Name): ROGER D. COHEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-3518
US

IV. Provider business mailing address

10000 W INNOVATION DR
MILWAUKEE WI
53226-4837
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone: 414-456-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number17508
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: