=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346325958
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSHAN KOTHANDARAM M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 474 FULTON AVE STE 203
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-884-4882
-----------------------------------------------------
Fax | 516-515-9903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 LINDEN ST
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-884-4882
-----------------------------------------------------
Fax | 516-515-9903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 219486
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------