Provider Demographics
NPI:1710932884
Name:KOTHARE, SANJEEV V (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:V
Last Name:KOTHARE
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 1:2001 MARCUS AVE STE W290
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1098
Mailing Address - Country:US
Mailing Address - Phone:516-465-5255
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE W290
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1098
Practice Address - Country:US
Practice Address - Phone:516-465-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2687542084N0600X, 2084S0012X, 2084N0402X
MA815472084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03749108Medicaid
PA063379Medicare ID - Type Unspecified
A400083400Medicare PIN
NY03749108Medicaid
NY03749108Medicaid