Basic Information
| Provider Information | |||||||||
| NPI: | 1619041498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COHEN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 HARBOR PARK DR | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110504602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168837100 | ||||||||
| FaxNumber: | 5168837474 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 GREAT NECK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110214308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164826747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 167750 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01145064 | 05 | NY | MEDICAID |