Provider Demographics
NPI:1992232193
Name:KOTHARI, SHANA (MD)
Entity type:Individual
Prefix:DR
First Name:SHANA
Middle Name:
Last Name:KOTHARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3886 PRINCETON LAKES WAY SW STE 240
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5511
Mailing Address - Country:US
Mailing Address - Phone:678-593-1280
Mailing Address - Fax:678-593-1290
Practice Address - Street 1:3886 PRINCETON LAKES WAY SW STE 240
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5511
Practice Address - Country:US
Practice Address - Phone:678-593-1280
Practice Address - Fax:678-593-1290
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.070937207R00000X
390200000X
GA101186207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program