Provider Demographics
NPI:1821024795
Name:KOTHARI, JAYESH M (MD)
Entity Type:Individual
Prefix:
First Name:JAYESH
Middle Name:M
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 1:4307 ROYAL FOX DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-8785
Mailing Address - Country:US
Mailing Address - Phone:630-587-2170
Mailing Address - Fax:
Practice Address - Street 1:4307 ROYAL FOX DR
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-8785
Practice Address - Country:US
Practice Address - Phone:630-587-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG05571Medicare UPIN