Provider Demographics
NPI:1477585123
Name:KOTHAWALA, MURTUZA (MD)
Entity Type:Individual
Prefix:
First Name:MURTUZA
Middle Name:
Last Name:KOTHAWALA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-456-3288
Mailing Address - Fax:727-456-3289
Practice Address - Street 1:615 E PRINCETON ST
Practice Address - Street 2:SUITE # 225
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1456
Practice Address - Country:US
Practice Address - Phone:407-897-3544
Practice Address - Fax:407-897-4016
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME1075012084N0402X
AL272772084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051004023OtherSE NEUROLOGY - BCBS
FL002540900Medicaid
AL009937668Medicaid
AL051557887Medicare ID - Type Unspecified
AL009937668Medicaid
FLDL893ZMedicare PIN
AL009937951Medicare ID - Type UnspecifiedENTERPRISE NEUROLOGY