Healthcare Provider Details

I. General information

NPI: 1063418366
Provider Name (Legal Business Name): SHANU NIKHIL KOTHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 VERDAE BLVD STE 202
GREENVILLE SC
29607-4029
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-676-1072
  • Fax:
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number38040
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number83043
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: