Healthcare Provider Details

I. General information

NPI: 1154637353
Provider Name (Legal Business Name): CHANDRASEKHAR KOTHAGUNDLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10030 GILEAD RD
HUNTERSVILLE NC
28078-7545
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-3789
  • Fax: 704-316-6785
Mailing address:
  • Phone: 704-316-3789
  • Fax: 704-316-6785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2021-03349
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27509
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: