Provider Demographics
NPI:1801129663
Name:KOHLI, SANJIVAN SINGH (MD)
Entity type:Individual
Prefix:
First Name:SANJIVAN
Middle Name:SINGH
Last Name:KOHLI
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 7087
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-7087
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:30230 RANCHO VIEJO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1557
Practice Address - Country:US
Practice Address - Phone:949-443-4303
Practice Address - Fax:949-443-4033
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109968207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB218860Medicare PIN