Provider Demographics
NPI:1265607394
Name:PUNITA P KOTHARI
Entity type:Organization
Organization Name:PUNITA P KOTHARI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PUNITA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KOTHARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-448-4553
Mailing Address - Street 1:485 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2611
Mailing Address - Country:US
Mailing Address - Phone:419-448-4553
Mailing Address - Fax:419-448-4553
Practice Address - Street 1:485 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2611
Practice Address - Country:US
Practice Address - Phone:419-448-4553
Practice Address - Fax:419-448-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0767371Medicaid
OHD33278Medicare UPIN
OH0625871Medicare PIN