Healthcare Provider Details

I. General information

NPI: 1396921755
Provider Name (Legal Business Name): SUDHA KOTHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 W 71ST ST STE 102
INDIANAPOLIS IN
46278-1785
US

IV. Provider business mailing address

168 IRVING AVE STE 402-A
PORT CHESTER NY
10573-4157
US

V. Phone/Fax

Practice location:
  • Phone: 317-388-0800
  • Fax: 317-388-0805
Mailing address:
  • Phone: 914-939-3143
  • Fax: 914-939-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number029333
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: