Healthcare Provider Details

I. General information

NPI: 1760545503
Provider Name (Legal Business Name): VIJAY C KATUKOTA, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 N PARK AVE
POMONA CA
91768-3028
US

IV. Provider business mailing address

1177 N PARK AVE
POMONA CA
91768-3028
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-9900
  • Fax: 909-623-1993
Mailing address:
  • Phone: 909-623-9900
  • Fax: 909-623-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA38343
License Number StateCA

VIII. Authorized Official

Name: VIJAY CHANDRA KATUKOTA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 909-623-9900