Healthcare Provider Details

I. General information

NPI: 1710932884
Provider Name (Legal Business Name): SANJEEV V KOTHARE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MARCUS AVE STE W290
NEW HYDE PARK NY
11042-1098
US

IV. Provider business mailing address

2001 MARCUS AVE STE W290
NEW HYDE PARK NY
11042-1098
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-5255
  • Fax:
Mailing address:
  • Phone: 516-465-5255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number268754
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number268754
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number268754
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: