Basic Information
| Provider Information | |||||||||
| NPI: | 1285951798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTHAVALE | ||||||||
| FirstName: | SUPRIYA | ||||||||
| MiddleName: | SHARMA | ||||||||
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| Credential: | D.O. | ||||||||
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| OtherLastName: | SHARMA | ||||||||
| OtherFirstName: | SUPRIYA | ||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3331 BAINBRIDGE AVE | ||||||||
| Address2: | MONTEFIORE MEDICAL CENTER, DEPT. OF PSYCHIATRY | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189207967 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3331 BAINBRIDGE AVE | ||||||||
| Address2: | MONTEFIORE MEDICAL CENTER, DEPT. OF PSYCHIATRY | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189207967 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 05/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | 274976 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0800X | 274976 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 274976 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.