Healthcare Provider Details

I. General information

NPI: 1346325958
Provider Name (Legal Business Name): ROSHAN KOTHANDARAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 FULTON AVE STE 203
HEMPSTEAD NY
11550-4101
US

IV. Provider business mailing address

14 LINDEN ST
GARDEN CITY NY
11530-1811
US

V. Phone/Fax

Practice location:
  • Phone: 516-884-4882
  • Fax: 516-515-9903
Mailing address:
  • Phone: 516-884-4882
  • Fax: 516-515-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number219486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: