Healthcare Provider Details

I. General information

NPI: 1134280795
Provider Name (Legal Business Name): KETAN HASHMUKH KOTHARI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1546 PRATT STREET
PHILADELPHIA PA
19124-1923
US

IV. Provider business mailing address

1546 PRATT STREET
PHILADELPHIA PA
19124-1923
US

V. Phone/Fax

Practice location:
  • Phone: 215-533-8555
  • Fax: 215-533-8656
Mailing address:
  • Phone: 215-533-8555
  • Fax: 215-533-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberSC004645L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: