Healthcare Provider Details

I. General information

NPI: 1598287328
Provider Name (Legal Business Name): CHANDRASEKHAR KOTHURU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22590 SHADY CT
CALIFORNIA MD
20619-5009
US

IV. Provider business mailing address

PO BOX 640
HOLLYWOOD MD
20636-0640
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-7045
  • Fax:
Mailing address:
  • Phone: 301-373-7900
  • Fax: 301-373-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD91038
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301113156
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: