Provider Demographics
NPI:1659358596
Name:KHOSLA, KIMBERLY COOK (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:COOK
Last Name:KHOSLA
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 1:76 REMICK BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8310
Mailing Address - Country:US
Mailing Address - Phone:937-885-4475
Mailing Address - Fax:937-885-3670
Practice Address - Street 1:76 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8310
Practice Address - Country:US
Practice Address - Phone:937-885-4475
Practice Address - Fax:937-885-3670
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073226208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D7322604OtherHUMANA
000000360983OtherANTHEM
1205294OtherUHC
522374873030OtherCARESOURCE
7956655OtherAETNA
11443924OtherCAQH#
OH2429894Medicaid
OH2429894Medicaid