Provider Demographics
NPI:1437153111
Name:KOTHARY, DEEPALI (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPALI
Middle Name:
Last Name:KOTHARY
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:PO BOX 1400
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22038-1400
Mailing Address - Country:US
Mailing Address - Phone:703-383-9543
Mailing Address - Fax:703-383-9532
Practice Address - Street 1:5999 BURKE COMMONS RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2880
Practice Address - Country:US
Practice Address - Phone:703-249-7700
Practice Address - Fax:703-528-4233
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234648207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I26336Medicare UPIN
DC491965Medicare ID - Type UnspecifiedTRAILBLAZER MEDICARE