Provider Demographics
NPI:1598345159
Name:KOTWAL, SHIVANI (DPM)
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:KOTWAL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10533 CORY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2711
Mailing Address - Country:US
Mailing Address - Phone:813-965-1496
Mailing Address - Fax:
Practice Address - Street 1:8851 BOARDROOM CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4888
Practice Address - Country:US
Practice Address - Phone:239-433-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPO4578213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program