Provider Demographics
NPI:1700097862
Name:SURJIT K. KAHLON, M.D., PROFESSIONAL CORP.
Entity type:Organization
Organization Name:SURJIT K. KAHLON, M.D., PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MADDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CORTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-982-2719
Mailing Address - Street 1:630 N 13TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4975
Mailing Address - Country:US
Mailing Address - Phone:909-982-2719
Mailing Address - Fax:909-946-9931
Practice Address - Street 1:630 N 13TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4975
Practice Address - Country:US
Practice Address - Phone:909-982-2719
Practice Address - Fax:909-946-9931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700097862Medicaid
CA1700097862Medicare PIN
CA370009125Medicare ID - Type UnspecifiedRAILROAD MEDICARE