Provider Demographics
NPI:1093002792
Name:KOTHARI, MANSI MUKESH (MD)
Entity Type:Individual
Prefix:
First Name:MANSI
Middle Name:MUKESH
Last Name:KOTHARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CITY BLVD W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2903
Mailing Address - Country:US
Mailing Address - Phone:714-456-6745
Mailing Address - Fax:714-456-7753
Practice Address - Street 1:333 CITY BLVD W
Practice Address - Street 2:SUITE 400
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2903
Practice Address - Country:US
Practice Address - Phone:714-456-6745
Practice Address - Fax:714-456-7753
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125059403207R00000X
CAA130825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1308250Medicaid
CACB219370Medicare PIN