Provider Demographics
NPI:1497195390
Name:KOTHARI, RAVISH ASHOKKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:RAVISH
Middle Name:ASHOKKUMAR
Last Name:KOTHARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:209-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:8 MED PARK STE 420
Practice Address - Street 2:NEUROLOGY
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-545-6072
Practice Address - Fax:803-545-6051
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL359092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC359098Medicaid