Healthcare Provider Details

I. General information

NPI: 1225356215
Provider Name (Legal Business Name): SANGAMITRA KOTHAPA M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 N BROADWAY
SANTA ANA CA
92701-3412
US

IV. Provider business mailing address

1226 N BROADWAY
SANTA ANA CA
92701-3412
US

V. Phone/Fax

Practice location:
  • Phone: 714-825-0940
  • Fax: 714-825-0944
Mailing address:
  • Phone: 714-825-0940
  • Fax: 714-825-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA43502
License Number StateCA

VIII. Authorized Official

Name: SANGAMITRA KOTHAPA
Title or Position: OWNER
Credential: M.D
Phone: 714-825-0940