Provider Demographics
NPI:1871505008
Name:KOTHARI, NILESHKUMAR KANTILAL (MD)
Entity Type:Individual
Prefix:DR
First Name:NILESHKUMAR
Middle Name:KANTILAL
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 1:1308 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2830
Mailing Address - Country:US
Mailing Address - Phone:601-250-0965
Mailing Address - Fax:
Practice Address - Street 1:1308 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2830
Practice Address - Country:US
Practice Address - Phone:601-250-0965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35399-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96197Medicare UPIN