Healthcare Provider Details

I. General information

NPI: 1114366796
Provider Name (Legal Business Name): NIKISHA ASHOK KOTHARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W RANDOL MILL RD STE 101
ARLINGTON TX
76012
US

IV. Provider business mailing address

9600 N CENTRAL EXPY STE 100
DALLAS TX
75231-5078
US

V. Phone/Fax

Practice location:
  • Phone: 817-261-9625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberS1632
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA149895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: