Provider Demographics
NPI:1326231838
Name:GOENKA, PRATICHI KOTHARI (MD)
Entity Type:Individual
Prefix:
First Name:PRATICHI
Middle Name:KOTHARI
Last Name:GOENKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRATICHI
Other - Middle Name:
Other - Last Name:KOTHARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26901 76TH AVE
Mailing Address - Street 2:CCMC, GME OFFICE, STE. 003
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1433
Mailing Address - Country:US
Mailing Address - Phone:631-745-5659
Mailing Address - Fax:
Practice Address - Street 1:26901 76TH AVE
Practice Address - Street 2:CCMC, GME OFFICE, STE. 003
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1433
Practice Address - Country:US
Practice Address - Phone:631-745-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT190621208000000X
NY261026-1208000000X
NJ25MA09227800208000000X
PAMD439291208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics