Provider Demographics
NPI:1295765279
Name:KOTAK, KANCHAN DINESH (MD)
Entity type:Individual
Prefix:
First Name:KANCHAN
Middle Name:DINESH
Last Name:KOTAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1445
Mailing Address - Country:US
Mailing Address - Phone:302-378-2656
Mailing Address - Fax:302-378-0343
Practice Address - Street 1:27 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1445
Practice Address - Country:US
Practice Address - Phone:302-378-2656
Practice Address - Fax:302-378-0343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE191214OtherMEDICARE
DE0000017601Medicaid
DE0000017601Medicaid
DE191214G45Medicare PIN