Provider Demographics
NPI:1710449962
Name:KOHLI, MIRANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
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 1:2639 UNIVERSITY AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3784
Mailing Address - Country:US
Mailing Address - Phone:608-263-0572
Mailing Address - Fax:608-662-4570
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-890-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75291207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program