Healthcare Provider Details

I. General information

NPI: 1245827856
Provider Name (Legal Business Name): ANISHA DURGA KOTHARI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S LANDMARK AVE
BLOOMINGTON IN
47403-5003
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 812-932-2387
  • Fax: 812-222-0104
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003156A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: