Provider Demographics
NPI:1023114006
Name:KOH, KILSAN (MD)
Entity type:Individual
Prefix:
First Name:KILSAN
Middle Name:
Last Name:KOH
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 1:1000 ALPINE AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3406
Mailing Address - Country:US
Mailing Address - Phone:303-443-1008
Mailing Address - Fax:303-417-1111
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3406
Practice Address - Country:US
Practice Address - Phone:303-443-1008
Practice Address - Fax:303-417-1111
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29339208600000X
CAG87774208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COO1293398Medicaid
CAA74124Medicare UPIN
COO1293398Medicaid
COC49211Medicare PIN