Healthcare Provider Details

I. General information

NPI: 1861474876
Provider Name (Legal Business Name): TUSHAR G KOTHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 932163
CLEVELAND OH
44193-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2160
  • Fax: 859-301-3932
Mailing address:
  • Phone: 586-412-4000
  • Fax: 586-412-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number32047
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: