Healthcare Provider Details

I. General information

NPI: 1821251968
Provider Name (Legal Business Name): GAUTAM HIMANSHU KOTHARI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 US HIGHWAY 130 STE 100
BORDENTOWN NJ
08505-2137
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-9400
  • Fax: 609-424-3517
Mailing address:
  • Phone: 609-267-9400
  • Fax: 609-424-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB08908900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: