Provider Demographics
NPI:1942207485
Name:MONI, KOCHICHERIL N (MD)
Entity Type:Individual
Prefix:MR
First Name:KOCHICHERIL
Middle Name:N
Last Name:MONI
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 1:1116 SW 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064
Mailing Address - Country:US
Mailing Address - Phone:386-362-0820
Mailing Address - Fax:386-362-0821
Practice Address - Street 1:1116 SW 11TH STREET
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064
Practice Address - Country:US
Practice Address - Phone:386-362-0820
Practice Address - Fax:386-362-0821
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2011-09-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
VA0101031293174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6085164Medicaid
VA6085164Medicaid
060000269Medicare ID - Type Unspecified