Provider Demographics
NPI:1982786273
Name:KOLA, MANOHAR (MD)
Entity Type:Individual
Prefix:
First Name:MANOHAR
Middle Name:
Last Name:KOLA
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 1:1770 E LAKE SHORE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3800
Mailing Address - Country:US
Mailing Address - Phone:217-422-6100
Mailing Address - Fax:833-784-5326
Practice Address - Street 1:1770 E LAKE SHORE DR STE 105
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3800
Practice Address - Country:US
Practice Address - Phone:217-422-6100
Practice Address - Fax:833-784-5326
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071409174400000X
IL036071409207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071409Medicaid
IL060040114OtherRAILROAD
ILL66786Medicare ID - Type Unspecified
IL036071409Medicaid