Healthcare Provider Details

I. General information

NPI: 1821024795
Provider Name (Legal Business Name): JAYESH M KOTHARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4307 ROYAL FOX DR
ST CHARLES IL
60174-8785
US

IV. Provider business mailing address

4307 ROYAL FOX DR
ST CHARLES IL
60174-8785
US

V. Phone/Fax

Practice location:
  • Phone: 630-587-2170
  • Fax:
Mailing address:
  • Phone: 630-587-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: