Healthcare Provider Details

I. General information

NPI: 1447372487
Provider Name (Legal Business Name): PURUSHOTHAM AND AKTHER J KOTHA M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 CENTER DR #400
LA MESA CA
91942-3068
US

IV. Provider business mailing address

8860 CENTER DR #400
LA MESA CA
91942-3068
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-1995
  • Fax:
Mailing address:
  • Phone: 619-229-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA415338
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA45440
License Number StateCA

VIII. Authorized Official

Name: MRS. AKTHER J KOTHA
Title or Position: PRES
Credential: MD
Phone: 619-229-1995