{
"Npi": {
"NPI": "1114973179",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KOTHUR",
"FirstName": "PRAVEENA",
"MiddleName": "R",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "M.D.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "KOTHUR",
"OtherFirstName": "PRAVEENA",
"OtherMiddleName": "R",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "MD",
"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "PO BOX 5148",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GLENDALE",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85312-5148",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "602-805-3129",
"MailingAddressFaxNumber": "888-355-6609",
"FirstLinePracticeLocationAddress": "6003 W THUNDERBIRD RD STE 1",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GLENDALE",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85306-4004",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "602-805-3129",
"PracticeLocationAddressFaxNumber": "888-355-6609",
"EnumerationDate": "05/25/2006",
"LastUpdateDate": "07/25/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207K00000X",
"TaxonomyName": "Allergy & Immunology Physician",
"LicenseNumber": "30666",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}