Healthcare Provider Details

I. General information

NPI: 1093002792
Provider Name (Legal Business Name): MANSI MUKESH KOTHARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W SUITE 400
ORANGE CA
92868-2903
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6745
  • Fax: 714-456-7753
Mailing address:
  • Phone: 847-570-2040
  • Fax: 847-733-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036181955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: