Healthcare Provider Details

I. General information

NPI: 1184157844
Provider Name (Legal Business Name): HARISH RAM KOTIPOYINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW COMMERCE DR
LAKE CITY FL
32055-4709
US

IV. Provider business mailing address

8016 NW 37TH RD APT 267
GAINESVILLE FL
32606-0046
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-9000
  • Fax:
Mailing address:
  • Phone: 863-513-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME144990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: