Provider Demographics
NPI:1104818830
Name:KOHAN, MITCHELL A (DPM)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:A
Last Name:KOHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 SMITHTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2043
Mailing Address - Country:US
Mailing Address - Phone:631-467-7600
Mailing Address - Fax:631-467-0945
Practice Address - Street 1:276 SMITHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2043
Practice Address - Country:US
Practice Address - Phone:631-467-7600
Practice Address - Fax:631-467-0945
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004249213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01081474Medicaid
T51409Medicare UPIN
P44701Medicare ID - Type Unspecified