Healthcare Provider Details

I. General information

NPI: 1396789616
Provider Name (Legal Business Name): BIPAN KOTWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 DR MARTIN LUTHER KING JR ST N SUITE 108
ST PETERSBURG FL
33701
US

IV. Provider business mailing address

1033 DR MARTIN LUTHER KING JR ST N SUITE 108
ST PETERSBURG FL
33701-1547
US

V. Phone/Fax

Practice location:
  • Phone: 727-456-4250
  • Fax: 727-346-1044
Mailing address:
  • Phone: 727-456-4250
  • Fax: 727-346-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME61574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: