Provider Demographics
NPI:1629277801
Name:KOHLI, SUPARNA (MD)
Entity Type:Individual
Prefix:
First Name:SUPARNA
Middle Name:
Last Name:KOHLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:INTERNAL MEDICINE
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-4360
Mailing Address - Fax:217-876-4365
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-4360
Practice Address - Fax:217-876-4365
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036123811207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2868038Medicare PIN