Provider Demographics
NPI:1811919657
Name:KOTWAL, AJOY (MD)
Entity type:Individual
Prefix:
First Name:AJOY
Middle Name:
Last Name:KOTWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 W CYPRESS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-874-1404
Mailing Address - Fax:813-874-9305
Practice Address - Street 1:3102 W CYPRESS ST
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-874-1404
Practice Address - Fax:813-874-9305
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL231261OtherWELLCARE
FL25921OtherBCBS
FLME0065983OtherSTATE LIC
FL270102OtherAVMED
FL231261OtherSTAYWELL
FL25921OtherBCBS
FL270102OtherAVMED