Healthcare Provider Details

I. General information

NPI: 1124069521
Provider Name (Legal Business Name): SIVARAMA KOTIKALAPUDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ASBURY CIR
HATTIESBURG MS
39402-1302
US

IV. Provider business mailing address

101 ASBURY CIR SOUTHERN STAR MEDICAL GROUP
HATTIESBURG MS
39402-1302
US

V. Phone/Fax

Practice location:
  • Phone: 601-450-2034
  • Fax: 601-450-2035
Mailing address:
  • Phone: 601-450-2034
  • Fax: 601-450-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18593
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: