Provider Demographics
NPI:1386842425
Name:KOHLER, NATHAN G (OD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:G
Last Name:KOHLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4329
Mailing Address - Country:US
Mailing Address - Phone:208-524-4552
Mailing Address - Fax:208-524-4559
Practice Address - Street 1:320 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4329
Practice Address - Country:US
Practice Address - Phone:208-524-4552
Practice Address - Fax:208-524-4559
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV5996OtherBLUE CROSS INDIVIDUAL
ID000010144177OtherBLUE SHIELD
ID806671900Medicaid
ID00034OtherVBA
ID21776OtherSPECTERA
ID00034OtherVBA
IDV5996OtherBLUE CROSS INDIVIDUAL