Healthcare Provider Details

I. General information

NPI: 1588825228
Provider Name (Legal Business Name): CHAITANYA KRISHNA KOTAGIRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W LIBERTY ST
FARMINGTON MO
63640-1921
US

IV. Provider business mailing address

1101 W LIBERTY ST
FARMINGTON MO
63640-1921
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-6751
  • Fax: 573-756-6807
Mailing address:
  • Phone: 573-751-6751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011017860
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2011017860
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-054995
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: