Provider Demographics
NPI:1447286497
Name:KOHLI, MANDEEP S (DO)
Entity type:Individual
Prefix:DR
First Name:MANDEEP
Middle Name:S
Last Name:KOHLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6365
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-6365
Mailing Address - Country:US
Mailing Address - Phone:630-893-0347
Mailing Address - Fax:630-893-1467
Practice Address - Street 1:303 E ARMY TRAIL RD
Practice Address - Street 2:STE 301
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2169
Practice Address - Country:US
Practice Address - Phone:630-893-0347
Practice Address - Fax:630-893-1467
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104504Medicaid
IL208828Medicare UPIN
ILH34276Medicare UPIN
IL036104504Medicaid