Healthcare Provider Details

I. General information

NPI: 1073873956
Provider Name (Legal Business Name): NISHA SURESH KOTECHA M.B.B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SPRINGFIELD AVE
SUMMIT NJ
07901-4055
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 908-934-0555
  • Fax:
Mailing address:
  • Phone: 973-656-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number25MA09765100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA09765100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: