Healthcare Provider Details

I. General information

NPI: 1891042552
Provider Name (Legal Business Name): AZHAR KOTHAWALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2012
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 N MULFORD RD STE 222
ROCKFORD IL
61107-3879
US

IV. Provider business mailing address

2202 HARLEM ROAD SUITE 200
LOVES PARK IL
61111-2754
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-8400
  • Fax: 815-229-0050
Mailing address:
  • Phone: 815-877-4848
  • Fax: 815-636-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036.140452
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.140452
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: