Healthcare Provider Details

I. General information

NPI: 1871563700
Provider Name (Legal Business Name): RENU O KOTHARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 POQUONNOCK RD
GROTON CT
06340-4571
US

IV. Provider business mailing address

591 POQUONNOCK RD
GROTON CT
06340-4571
US

V. Phone/Fax

Practice location:
  • Phone: 860-449-8217
  • Fax: 860-449-8323
Mailing address:
  • Phone: 860-449-8217
  • Fax: 860-449-8323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5601
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20325
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD05601
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20325
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: