Provider Demographics
NPI:1659358596
Name:KHOSLA, KIMBERLY COOK (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:COOK
Last Name:KHOSLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3555
Mailing Address - Fax:937-641-4528
Practice Address - Street 1:1010 VALLEY ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-2070
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-4500
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073226208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000360983OtherANTHEM
OH2429894Medicaid
522374873030OtherCARESOURCE
D7322604OtherHUMANA
11443924OtherCAQH#
7956655OtherAETNA
1205294OtherUHC
7956655OtherAETNA
36D1007721OtherCLIA