=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104388073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN COHEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2019
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4735 OGLETOWN STANTON RD STE 3302
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-602-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 748 STONEHOUSE WAY
-----------------------------------------------------
City | HOCKESSIN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19707-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | C2-0024484
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------