Healthcare Provider Details

I. General information

NPI: 1134231293
Provider Name (Legal Business Name): JONATHAN EMERSON KOHLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 STOCKTON BLVD STE 517
SACRAMENTO CA
95817-2215
US

IV. Provider business mailing address

2425 STOCKTON BLVD STE 517
SACRAMENTO CA
95817-2215
US

V. Phone/Fax

Practice location:
  • Phone: 916-453-2080
  • Fax:
Mailing address:
  • Phone: 916-453-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number64492-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: