Provider Demographics
NPI:1285951798
Name:KOTHAVALE, SUPRIYA SHARMA (DO)
Entity type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:SHARMA
Last Name:KOTHAVALE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUPRIYA
Other - Middle Name:
Other - Last Name:SHARMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:8707 RIDGEHILL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7342
Mailing Address - Country:US
Mailing Address - Phone:908-692-1792
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD STE H2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8659
Practice Address - Country:US
Practice Address - Phone:512-706-9821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR75102084P0015X, 2084P0800X, 2084P0804X
NY2749762084P0015X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty