Provider Demographics
NPI:1538331723
Name:KOTHARI, KIRIT K (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRIT
Middle Name:K
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:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-0637
Mailing Address - Country:US
Mailing Address - Phone:570-992-1234
Mailing Address - Fax:570-992-8610
Practice Address - Street 1:RT 115 & SWITZGABLE RD
Practice Address - Street 2:
Practice Address - City:BROHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-0637
Practice Address - Country:US
Practice Address - Phone:570-992-1234
Practice Address - Fax:570-992-8610
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA050895L207LP2900X, 207N00000X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01601248Medicaid
PA882797Medicare PIN
PA01601248Medicaid