Healthcare Provider Details

I. General information

NPI: 1205322393
Provider Name (Legal Business Name): HARJIVAN SINGH KOHLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BASTANCHURY RD STE 180
FULLERTON CA
92835-3427
US

IV. Provider business mailing address

1515 SAN JOAQUIN PLZ
NEWPORT BEACH CA
92660-5964
US

V. Phone/Fax

Practice location:
  • Phone: 714-870-5970
  • Fax:
Mailing address:
  • Phone: 619-519-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number187272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: