Healthcare Provider Details

I. General information

NPI: 1104878131
Provider Name (Legal Business Name): JEHANGIR KEKI KOTWAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 GENESEE ST
UTICA NY
13501-4343
US

IV. Provider business mailing address

1020 MARY ST
UTICA NY
13501-1930
US

V. Phone/Fax

Practice location:
  • Phone: 315-738-1428
  • Fax: 315-738-1461
Mailing address:
  • Phone: 315-724-6907
  • Fax: 315-733-0791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number113524-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: