Provider Demographics
NPI:1184615742
Name:KOHANOV, PHILLIP A (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:A
Last Name:KOHANOV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4100
Mailing Address - Country:US
Mailing Address - Phone:810-985-5600
Mailing Address - Fax:910-985-5740
Practice Address - Street 1:3833 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4100
Practice Address - Country:US
Practice Address - Phone:810-985-5600
Practice Address - Fax:910-985-5740
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1038350001OtherREGION B DMERC
MI900G465140OtherBLUE CROSS BLUE SHIELD
MIU29926Medicare UPIN
MI900G465140OtherBLUE CROSS BLUE SHIELD