Healthcare Provider Details

I. General information

NPI: 1336189885
Provider Name (Legal Business Name): ANIL KOTHARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E LINCOLNWAY
VALPARAISO IN
46383-5803
US

IV. Provider business mailing address

825 E LINCOLNWAY
VALPARAISO IN
46383-5803
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-4891
  • Fax: 219-464-1873
Mailing address:
  • Phone: 219-464-4891
  • Fax: 219-464-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01030081A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: