Healthcare Provider Details

I. General information

NPI: 1386349447
Provider Name (Legal Business Name): BHARAT KOTHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD STE 80
DETROIT MI
48236-2169
US

IV. Provider business mailing address

22201 MOROSS RD STE 80
DETROIT MI
48236-2169
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-3800
  • Fax: 313-343-4756
Mailing address:
  • Phone: 313-343-3800
  • Fax: 313-343-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: