Healthcare Provider Details

I. General information

NPI: 1164788709
Provider Name (Legal Business Name): VANITHA DORAIRAJAN KOTHAPALLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY DEPT. OF PSYCHAITRY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1541 KINGS HWY ATTN: PAYOR CREDENTIALING
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-6619
  • Fax: 318-675-6148
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number300496
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: