Provider Demographics
NPI:1871563700
Name:KOTHARI, RENU O (MD)
Entity type:Individual
Prefix:
First Name:RENU
Middle Name:O
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 1:591 POQUONNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4571
Mailing Address - Country:US
Mailing Address - Phone:860-449-8217
Mailing Address - Fax:860-449-8323
Practice Address - Street 1:591 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4571
Practice Address - Country:US
Practice Address - Phone:860-449-8217
Practice Address - Fax:860-449-8323
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI56012084P0800X
CT203252084P0804X, 2084P0800X
RIMD056012084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008035572Medicaid
RI7001845Medicaid
RI7001845Medicaid