Healthcare Provider Details

I. General information

NPI: 1528214970
Provider Name (Legal Business Name): GOPI KOTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

4150 KIMBALL AVENUE PO BOX 2758
WATERLOO IA
50704-2758
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-5386
  • Fax:
Mailing address:
  • Phone: 319-235-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number40724
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: