Basic Information
| Provider Information | |||||||||
| NPI: | 1548463003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLA | ||||||||
| FirstName: | MOIN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N DEAN RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328253710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073847388 | ||||||||
| FaxNumber: | 4073847391 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 N ORANGE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328045505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073031812 | ||||||||
| FaxNumber: | 4073031815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME101271 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001997900 | 05 | FL | MEDICAID |