Healthcare Provider Details

I. General information

NPI: 1376505263
Provider Name (Legal Business Name): KAVITHA S KOTRAPPA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W. FOOTHILL BLVD
SAN DIMAS CA
91773-1102
US

IV. Provider business mailing address

150 W. FOOTHILL BLVD
SAN DIMAS CA
91773-1102
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-9921
  • Fax: 909-592-3147
Mailing address:
  • Phone: 909-599-9921
  • Fax: 909-592-3147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA53418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: