Provider Demographics
NPI:1346325958
Name:KOTHANDARAM, ROSHAN (MD)
Entity Type:Individual
Prefix:
First Name:ROSHAN
Middle Name:
Last Name:KOTHANDARAM
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 1:14 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1811
Mailing Address - Country:US
Mailing Address - Phone:516-884-4882
Mailing Address - Fax:516-515-9903
Practice Address - Street 1:474 FULTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4101
Practice Address - Country:US
Practice Address - Phone:516-884-4882
Practice Address - Fax:516-515-9903
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02132350Medicaid
NYH30588Medicare UPIN
NY111L01Medicare PIN