Basic Information
Provider Information | |||||||||
NPI: | 1659371441 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOHLHEPP | ||||||||
FirstName: | MARGUERITE | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 VONDERBURG DR | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136811122 | ||||||||
FaxNumber: | 8136844924 | ||||||||
Practice Location | |||||||||
Address1: | 403 VONDERBURG DR | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136811122 | ||||||||
FaxNumber: | 8136844924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2005 | ||||||||
LastUpdateDate: | 05/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME0076125 | FL | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207WX0107X | ME76125 | FL | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 58545 | 01 | FL | BCBSFL | OTHER | 3353345 | 01 | FL | CIGNA | OTHER | 9666437 | 01 | NY | GHI | OTHER | 7514064 | 01 | FL | AETNA | OTHER | 264786900 | 05 | FL |   | MEDICAID |