Provider Demographics
NPI:1902564719
Name:KOTHADIA, SHRUTI ANTARIX
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:ANTARIX
Last Name:KOTHADIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12242 SILVER MAPLE
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9216
Mailing Address - Country:US
Mailing Address - Phone:708-870-0345
Mailing Address - Fax:
Practice Address - Street 1:1400 BROOKDALE RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2126
Practice Address - Country:US
Practice Address - Phone:630-416-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007645225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant