Provider Demographics
NPI:1457537359
Name:KOTHARI, MANOJ RATILAL
Entity Type:Individual
Prefix:MR
First Name:MANOJ
Middle Name:RATILAL
Last Name:KOTHARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-7011
Mailing Address - Country:US
Mailing Address - Phone:212-974-6013
Mailing Address - Fax:
Practice Address - Street 1:771 8TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7011
Practice Address - Country:US
Practice Address - Phone:212-974-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033389183500000X
NJ28RI01927200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01731566Medicaid