Provider Demographics
NPI:1508243627
Name:KOTHARI, SOOR NILESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SOOR
Middle Name:NILESH
Last Name:KOTHARI
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1234
Mailing Address - Country:US
Mailing Address - Phone:860-679-4272
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:GENERAL MEDICINE CLINIC MC8021 OUTPATIENT PAVILION 2E
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1234
Practice Address - Country:US
Practice Address - Phone:860-679-4272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD046629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program