Healthcare Provider Details

I. General information

NPI: 1992147607
Provider Name (Legal Business Name): SAMUEL S KOTHALANKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-3000
  • Fax:
Mailing address:
  • Phone: 617-789-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number256865
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: