Healthcare Provider Details

I. General information

NPI: 1063668614
Provider Name (Legal Business Name): KOTA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

IV. Provider business mailing address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

V. Phone/Fax

Practice location:
  • Phone: 219-759-5812
  • Fax: 219-759-5890
Mailing address:
  • Phone: 219-759-5812
  • Fax: 219-759-5890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01038987
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01038987
License Number StateIN

VIII. Authorized Official

Name: RANGA RAO KOTA
Title or Position: OWNER
Credential: MD
Phone: 219-759-5812