Basic Information
Provider Information | |||||||||
NPI: | 1023047438 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COEN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10069 | ||||||||
Address2: |   | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924230069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093354188 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7000 BOULDER AVE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 923463348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098621191 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 04/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35070748 | OH | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | G72913 | CA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 00G729130 | 05 | CA |   | MEDICAID | 0257823 | 05 | OH |   | MEDICAID |