Healthcare Provider Details

I. General information

NPI: 1871012922
Provider Name (Legal Business Name): FENILKUMAR SHAMBHUBHAI KOTADIYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE STE B-16
CHARLESTON WV
25304-1297
US

IV. Provider business mailing address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5848
  • Fax: 304-388-9654
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number29597
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: