Provider Demographics
NPI:1891042552
Name:KOTHAWALA, AZHAR (MD)
Entity Type:Individual
Prefix:DR
First Name:AZHAR
Middle Name:
Last Name:KOTHAWALA
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 1:2202 HARLEM ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:1235 N MULFORD RD STE 222
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-397-8400
Practice Address - Fax:815-229-0050
Is Sole Proprietor?:No
Enumeration Date:2012-08-12
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.140452207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036140452Medicaid
IL036140452Medicaid
F400315730Medicare PIN