Healthcare Provider Details

I. General information

NPI: 1245636596
Provider Name (Legal Business Name): JITEN P KOTHADIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVENUE 4 SHORB TOWER
MEMPHIS TN
38104-4418
US

IV. Provider business mailing address

P O BOX 1000 DEPT 457
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-478-9183
  • Fax: 901-478-8957
Mailing address:
  • Phone: 901-478-9183
  • Fax: 901-478-8957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number59366
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number59366
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: