Provider Demographics
NPI:1871525998
Name:KOHL, ROY (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:KOHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 SAN PABLO ST
Mailing Address - Street 2:SUITE 4300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5310
Mailing Address - Country:US
Mailing Address - Phone:323-442-5849
Mailing Address - Fax:323-442-6798
Practice Address - Street 1:10 CONGRESS ST
Practice Address - Street 2:SUITE 504
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3045
Practice Address - Country:US
Practice Address - Phone:323-442-5849
Practice Address - Fax:323-442-6798
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17126208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770002257OtherMEDICARE RAILROAD
CA00G171260F94OtherCAL OPTIMA PIN
CA00G171260C29OtherCAL OPTIMA PIN
CA00G171260OtherBLUE SHIELD PIN
CA00G171260Medicaid
CAP00416526OtherMEDICARE RAILROAD PIN
CA00G171260OtherBLUE SHIELD PIN
CA770002257OtherMEDICARE RAILROAD
CA00G171260Medicaid
CA00G171260C29OtherCAL OPTIMA PIN
CAWG17126EMedicare PIN