Healthcare Provider Details

I. General information

NPI: 1649569393
Provider Name (Legal Business Name): DIVYANSHOO RAI KOHLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE STE 7050
SPOKANE WA
99204-2362
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-252-1711
  • Fax: 509-227-7070
Mailing address:
  • Phone: 509-474-3568
  • Fax: 509-227-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2018008784
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number2018008784
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD61259570
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: