Provider Demographics
NPI:1548298375
Name:KOCHERIL, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KOCHERIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2044
Mailing Address - Country:US
Mailing Address - Phone:810-762-8490
Mailing Address - Fax:
Practice Address - Street 1:302 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2044
Practice Address - Country:US
Practice Address - Phone:810-762-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPK0664262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4258108Medicaid
MI320Z910000OtherBLUE CROSS
MI1548298375Medicaid
MI320Z901020OtherBLUE CROSS
MI320Z910000OtherBLUE CROSS
MI0N21860001Medicare PIN
MI4258108Medicaid