Provider Demographics
NPI:1700827003
Name:DHOLAKIA, KUSH R
Entity Type:Individual
Prefix:
First Name:KUSH
Middle Name:R
Last Name:DHOLAKIA
Suffix:
Gender:M
Credentials:
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 64075
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 E SHORE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2433
Practice Address - Country:US
Practice Address - Phone:516-482-7810
Practice Address - Fax:516-829-6887
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63326207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS 185 / 0029OtherBLUECHOICE
MDKX 46 / 646236-01OtherBC / BS OF MD
368 L / M 088Medicare ID - Type Unspecified
MDS 185 / 0029OtherBLUECHOICE