Basic Information
| Provider Information | |||||||||
| NPI: | 1730241308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COHEN | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | COHEN | ||||||||
| OtherFirstName: | MARVIN | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775555302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1804 FM 646 W | ||||||||
| Address2: | STE N | ||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | H5509 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207Y00000X | H5509 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 135610701 | 05 | TX | MEDICAID |