Provider Demographics
NPI:1114973179
Name:KOTHUR, PRAVEENA R (MD)
Entity type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:R
Last Name:KOTHUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRAVEENA
Other - Middle Name:R
Other - Last Name:KOTHUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5148
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85312-5148
Mailing Address - Country:US
Mailing Address - Phone:602-805-3129
Mailing Address - Fax:888-355-6609
Practice Address - Street 1:6003 W THUNDERBIRD RD STE 1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4004
Practice Address - Country:US
Practice Address - Phone:602-805-3129
Practice Address - Fax:888-355-6609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30666207K00000X
AZAZ30666207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ792053Medicaid
AZZ302567OtherMEDICARE PTAN
F92368Medicare UPIN