Healthcare Provider Details

I. General information

NPI: 1124452628
Provider Name (Legal Business Name): RANGA KOTA MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 09/03/2013
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01038987
License Number StateIN

VIII. Authorized Official

Name: SUZI SINDE
Title or Position: CREDENTIALING SPECIALIST, CDS
Credential:
Phone: 219-769-1670