Provider Demographics
NPI:1770681470
Name:KOHLI, VINOD K (MD)
Entity Type:Individual
Prefix:
First Name:VINOD
Middle Name:K
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 1:23700 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1669
Mailing Address - Country:US
Mailing Address - Phone:586-759-6300
Mailing Address - Fax:586-759-1409
Practice Address - Street 1:23700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1669
Practice Address - Country:US
Practice Address - Phone:586-759-6300
Practice Address - Fax:586-759-1409
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301-040989208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI335057710Medicaid
B47210Medicare UPIN
MIMI335057710Medicaid