Provider Demographics
NPI:1013023357
Name:KOTAK, SANDEEP V (MD)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:V
Last Name:KOTAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 AUBURN ROAD, SUITE 014
Mailing Address - Street 2:ATTN: MED STAFF
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:36100 EUCLID AVE STE 240
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4427
Practice Address - Country:US
Practice Address - Phone:440-953-6294
Practice Address - Fax:440-918-4687
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-070626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2042211Medicaid
OH0882947Medicare PIN
OH2042211Medicaid