Provider Demographics
NPI:1679517239
Name:KOHATSU, KAREN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KOHATSU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11939 RANCHO BERNARDO RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2073
Mailing Address - Country:US
Mailing Address - Phone:858-613-8949
Mailing Address - Fax:858-613-8953
Practice Address - Street 1:11939 RANCHO BERNARDO RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2073
Practice Address - Country:US
Practice Address - Phone:858-613-8949
Practice Address - Fax:858-613-8953
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70665207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G706650Medicaid
CA330322941OtherTRICARE
CA00G706650OtherBLUE SHIELD
CAF55172Medicare UPIN
CA00G706650Medicaid