Healthcare Provider Details

I. General information

NPI: 1013185107
Provider Name (Legal Business Name): SAMIP DHIREN KOTHARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 N WATER ST APT 403
MILWAUKEE WI
53202-1588
US

IV. Provider business mailing address

1925 N WATER ST APT 403
MILWAUKEE WI
53202-1588
US

V. Phone/Fax

Practice location:
  • Phone: 608-347-1776
  • Fax:
Mailing address:
  • Phone: 608-347-1776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81151
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: