Basic Information
| Provider Information | |||||||||
| NPI: | 1700097862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURJIT K. KAHLON, M.D., PROFESSIONAL CORP. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 630 N 13TH AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099822719 | ||||||||
| FaxNumber: | 9099469931 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 N 13TH AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099822719 | ||||||||
| FaxNumber: | 9099469931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | CORTEZ | ||||||||
| AuthorizedOfficialFirstName: | MADDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9099822719 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A31422 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1700097862 | 05 | CA | MEDICAID |