Healthcare Provider Details

I. General information

NPI: 1205825312
Provider Name (Legal Business Name): GODSON G KOTIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 E. CHICAGO ROAD
STURGIS MI
49091
US

IV. Provider business mailing address

1904 E. CHICAGO ROAD
STURGIS MI
49091
US

V. Phone/Fax

Practice location:
  • Phone: 269-651-7003
  • Fax: 269-651-8970
Mailing address:
  • Phone: 269-651-7003
  • Fax: 269-651-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberGK078341
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301078341
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: