Healthcare Provider Details

I. General information

NPI: 1730445644
Provider Name (Legal Business Name): NISREEN MESIWALA KOTHARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15051 HESPERIAN BLVD STE A
SAN LEANDRO CA
94578
US

IV. Provider business mailing address

250 KING ST UNIT 432
SAN FRANCISCO CA
94107-5488
US

V. Phone/Fax

Practice location:
  • Phone: 510-276-1212
  • Fax:
Mailing address:
  • Phone: 248-760-9236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberRS2014-0672
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number262309
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA144488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: