Provider Demographics
NPI:1154612430
Name:KATHROTIA, MITESH GORDHAN (MD)
Entity type:Individual
Prefix:
First Name:MITESH
Middle Name:GORDHAN
Last Name:KATHROTIA
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 1:300 E 46TH ST
Mailing Address - Street 2:APT 6B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-3000
Mailing Address - Country:US
Mailing Address - Phone:805-452-0536
Mailing Address - Fax:
Practice Address - Street 1:17 BROAD ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-1757
Practice Address - Country:US
Practice Address - Phone:732-780-1601
Practice Address - Fax:732-780-1936
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09498400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program