Provider Demographics
NPI:1578175725
Name:KOHLI, TANYA (OD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:KOHLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 E RIVERSIDE DR APT 2428
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-5045
Mailing Address - Country:US
Mailing Address - Phone:972-795-4579
Mailing Address - Fax:
Practice Address - Street 1:13343 N US HIGHWAY 183 STE 215
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-7167
Practice Address - Country:US
Practice Address - Phone:972-795-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9779T152W00000X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision