1346325958 NPI number — ROSHAN KOTHANDARAM M.D

Table of content: DR. ERIN M. ODONOHUE PSY.D. (NPI 1245569268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346325958 NPI number — ROSHAN KOTHANDARAM M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOTHANDARAM
Provider First Name:
ROSHAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346325958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 LINDEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11530-1811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-884-4882
Provider Business Mailing Address Fax Number:
516-515-9903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
474 FULTON AVE STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMPSTEAD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11550-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-884-4882
Provider Business Practice Location Address Fax Number:
516-515-9903
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  219486 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02132350 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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