Provider Demographics
NPI:1255338760
Name:COHEN, EDWARD ROBERT (DPM)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ROBERT
Last Name:COHEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12056 MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3004
Mailing Address - Country:US
Mailing Address - Phone:228-832-4475
Mailing Address - Fax:228-832-1512
Practice Address - Street 1:12056 MOBILE AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3113
Practice Address - Country:US
Practice Address - Phone:228-832-4475
Practice Address - Fax:228-832-1512
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS640616729213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2730008OtherUHC
MS00016981Medicaid
MS409879OtherWINDSOR MEDICARE EXTRA
MS406480354AMedicare ID - Type UnspecifiedRAILROAD MEDICARE
MS0657170001Medicare NSC
MS480948130Medicare PIN