Provider Demographics
NPI:1225137722
Name:KOHLER, DORREL DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DORREL
Middle Name:DOUGLAS
Last Name:KOHLER
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 1:1055 N 300 W
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7444
Mailing Address - Fax:
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 302
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT151624-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD99959Medicare UPIN