Basic Information
| Provider Information | |||||||||
| NPI: | 1245334721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COHEN | ||||||||
| FirstName: | ZAZA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | KOYENISHVILI | ||||||||
| OtherFirstName: | ZAZA | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1253 SPRINGFIELD AVE | ||||||||
| Address2: | SUITE 332 | ||||||||
| City: | NEW PROVIDENCE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079742931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732290308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 BAY AVE | ||||||||
| Address2: | MOUNTAINSIDE HOSPITAL, DEPARTMENT OF MEDICINE | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070424837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734296874 | ||||||||
| FaxNumber: | 9734296575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 25MA07622700 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 25MA07622700 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 25MA07622700 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0029173 | 05 | NJ | MEDICAID |