Provider Demographics
NPI:1669864856
Name:KOTHARY, SUDHANSU (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHANSU
Middle Name:
Last Name:KOTHARY
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 478
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-0010
Mailing Address - Country:US
Mailing Address - Phone:573-581-8127
Mailing Address - Fax:573-582-7053
Practice Address - Street 1:626 E SUMMIT ST
Practice Address - Street 2:SUITE L
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3298
Practice Address - Country:US
Practice Address - Phone:573-581-6266
Practice Address - Fax:573-581-0955
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.44375207Q00000X
GA5494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine