Provider Demographics
NPI:1508973744
Name:KOTHARI, PURNIMA A (MD)
Entity Type:Individual
Prefix:
First Name:PURNIMA
Middle Name:A
Last Name:KOTHARI
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 1:20800 WESTGATE MALL
Mailing Address - Street 2:#206
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1323
Mailing Address - Country:US
Mailing Address - Phone:440-331-4666
Mailing Address - Fax:
Practice Address - Street 1:20800 WESTGATE MALL
Practice Address - Street 2:#206
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44126-1323
Practice Address - Country:US
Practice Address - Phone:440-331-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-044273207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0457527Medicaid
000000380518OtherANTHEM
KO0542492Medicare ID - Type Unspecified
OH0457527Medicaid