Provider Demographics
NPI:1164563847
Name:KOHLS, GARY GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:GEORGE
Last Name:KOHLS
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 1:8 N 2ND AVE E
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 N 2ND AVE E
Practice Address - Street 2:SUITE 209
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2102
Practice Address - Country:US
Practice Address - Phone:218-628-2130
Practice Address - Fax:218-727-2712
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND46710Medicare UPIN