Provider Demographics
NPI:1952633323
Name:JAMES JACK KOHAN MD LLC
Entity Type:Organization
Organization Name:JAMES JACK KOHAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-352-2501
Mailing Address - Street 1:PO BOX 700309
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96709-0309
Mailing Address - Country:US
Mailing Address - Phone:808-203-7943
Mailing Address - Fax:808-693-8060
Practice Address - Street 1:2658 DEL MAR HEIGHTS RD
Practice Address - Street 2:#358
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-3100
Practice Address - Country:US
Practice Address - Phone:808-352-2501
Practice Address - Fax:858-755-3758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13365207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000291385OtherHMSA
HI569337-02Medicaid
HID02177Medicare UPIN
HI569337-02Medicaid