Provider Demographics
NPI:1447284385
Name:COHENZADEH, ELIAS (MD)
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:COHENZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4702
Mailing Address - Country:US
Mailing Address - Phone:310-951-5453
Mailing Address - Fax:
Practice Address - Street 1:1034 PRINCETON ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4702
Practice Address - Country:US
Practice Address - Phone:310-951-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36930208D00000X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36930OtherPROFESSIONAL LICENSE
CA00A369300Medicaid
CAA36930OtherPROFESSIONAL LICENSE
CAA36930BMedicare ID - Type Unspecified