Provider Demographics
NPI:1194033548
Name:BOTHRA, ASHEESH (MB,BS)
Entity type:Individual
Prefix:DR
First Name:ASHEESH
Middle Name:
Last Name:BOTHRA
Suffix:
Gender:
Credentials:MB,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:888-812-8191
Practice Address - Street 1:1920 COUNTRY PLACE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2282
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:800-991-6117
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV3753202K00000X, 207R00000X
OH35.133856207R00000X
PAMD443129208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074869Medicaid