Provider Demographics
NPI:1477811479
Name:KOTHARI, NILANJANA
Entity Type:Individual
Prefix:
First Name:NILANJANA
Middle Name:
Last Name:KOTHARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E MUIRWOOD DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7693
Mailing Address - Country:US
Mailing Address - Phone:480-961-2303
Mailing Address - Fax:480-961-2306
Practice Address - Street 1:10440 E RIGGS RD STE 160
Practice Address - Street 2:
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7757
Practice Address - Country:US
Practice Address - Phone:480-895-2049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-37235207R00000X
AZ53629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ303825Medicaid