Provider Demographics
NPI:1013105899
Name:KOHL, SHANE K (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:K
Last Name:KOHL
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:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-4540
Practice Address - Fax:402-354-4535
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048195207ZP0102X
NE24106207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00048195OtherMEDICAL LICENSE
IA1013105899Medicaid
NE24106OtherMEDICAL LICENSE
NE47037660422Medicaid
NE24106OtherMEDICAL LICENSE