Healthcare Provider Details

I. General information

NPI: 1841492733
Provider Name (Legal Business Name): SHAVETA KOTWAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2007
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21170 ASHBY PONDS BLVD.
ASHBURN VA
20147
US

IV. Provider business mailing address

5730 EXECUTIVE DR STE 230
CATONSVILLE MD
21228-1762
US

V. Phone/Fax

Practice location:
  • Phone: 571-291-6131
  • Fax: 571-291-6135
Mailing address:
  • Phone: 571-291-6131
  • Fax: 571-291-6135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101244163
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024-02927
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101244163
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: