Provider Demographics
NPI:1003858200
Name:KOTHANDAN, SRIRAM (RPT)
Entity Type:Individual
Prefix:MR
First Name:SRIRAM
Middle Name:
Last Name:KOTHANDAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUNFLOWER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5630
Practice Address - Country:US
Practice Address - Phone:631-226-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028054-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist