Provider Demographics
NPI:1730279514
Name:KOTHARI, VIPUL
Entity Type:Individual
Prefix:DR
First Name:VIPUL
Middle Name:
Last Name:KOTHARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:VIPUL
Other - Middle Name:
Other - Last Name:KOTHARI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:121 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5425
Mailing Address - Country:US
Mailing Address - Phone:212-250-8671
Mailing Address - Fax:212-250-6894
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:212-250-8671
Practice Address - Fax:212-250-6894
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174887208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158507Medicaid