Healthcare Provider Details

I. General information

NPI: 1285951798
Provider Name (Legal Business Name): SUPRIYA SHARMA KOTHAVALE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUPRIYA SHARMA D.O.

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 SPICEWOOD SPRINGS RD STE H2
AUSTIN TX
78759-8659
US

IV. Provider business mailing address

8707 RIDGEHILL DR
AUSTIN TX
78759-7342
US

V. Phone/Fax

Practice location:
  • Phone: 512-706-9821
  • Fax:
Mailing address:
  • Phone: 908-692-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberR7510
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number274976
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number274976
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR7510
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number274976
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberR7510
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: