Provider Demographics
NPI:1407804040
Name:KOHLI, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:KOHLI
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 1:2000 CIRCLE OF HOPE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5550
Mailing Address - Country:US
Mailing Address - Phone:801-646-4018
Mailing Address - Fax:
Practice Address - Street 1:2000 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-646-4018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60238069207RH0003X
MN103605207RX0202X
MN50887207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00739702OtherRAILROAD MEDICARE
MNENROLLEDMedicaid
WI35331200Medicaid
IAENROLLEDMedicaid
WI35331200Medicaid