Provider Demographics
NPI:1134280795
Name:KOTHARI, KETAN HASHMUKH (DPM)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:HASHMUKH
Last Name:KOTHARI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1546 PRATT STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-1923
Mailing Address - Country:US
Mailing Address - Phone:215-533-8555
Mailing Address - Fax:215-533-8656
Practice Address - Street 1:1546 PRATT STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-1923
Practice Address - Country:US
Practice Address - Phone:215-533-8555
Practice Address - Fax:215-533-8656
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004645L213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018311680001Medicaid
PAK0830767OtherBLUE SHIELD
PA246839OtherFIRST HEALTH
U81914OtherUNITED
480032950OtherRAIL ROAD MEDICARE
PA3075350OtherAETNA
PA30004716OtherKEYSTONE MERCY
U8914OtherHEALTH PARTNERS
480032950OtherRAIL ROAD MEDICARE
PA3075350OtherAETNA