Healthcare Provider Details

I. General information

NPI: 1538328612
Provider Name (Legal Business Name): DIPTI BHAVESH KOTHARI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 COMMUNITY DR
SMITHTOWN NY
11787-3875
US

IV. Provider business mailing address

262 COMMUNITY DR
SMITHTOWN NY
11787-3875
US

V. Phone/Fax

Practice location:
  • Phone: 952-412-4161
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number255736
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: