Provider Demographics
NPI:1245287515
Name:KOTHARI, MADHUBALA A (MD)
Entity type:Individual
Prefix:
First Name:MADHUBALA
Middle Name:A
Last Name:KOTHARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1860 TOWN CENTER DR
Mailing Address - Street 2:STE 210
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5905
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-455-2101
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:STE 210
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5905
Practice Address - Country:US
Practice Address - Phone:330-455-0374
Practice Address - Fax:330-455-2101
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012638352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7610021Medicaid