Basic Information
| Provider Information | |||||||||
| NPI: | 1639427396 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AJOY KOTWAL MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3102 W CYPRESS ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336075118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138741404 | ||||||||
| FaxNumber: | 8138749305 | ||||||||
| Practice Location | |||||||||
| Address1: | 3102 W CYPRESS ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336075118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138741404 | ||||||||
| FaxNumber: | 8138749305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | KOTWAL | ||||||||
| AuthorizedOfficialFirstName: | AJOY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8138741404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0065983 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 270102 | 01 | FL | AVMED | OTHER | 25921 | 01 | FL | BCBS | OTHER |