Healthcare Provider Details

I. General information

NPI: 1952693558
Provider Name (Legal Business Name): SUREKHA KOTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2011
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 RACE TRACK RD
SAINT JOHNS FL
32259-6278
US

IV. Provider business mailing address

275 ARELLA WAY
SAINT JOHNS FL
32259-1252
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-6718
  • Fax:
Mailing address:
  • Phone: 48-067-8149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS57398
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP444286
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: