Healthcare Provider Details

I. General information

NPI: 1316028590
Provider Name (Legal Business Name): SUDHARANI SUBBA KOTHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KOTHA SUBBA SUDHARANI MD

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 GUY R BREWER BLVD
JAMAICA NY
11434-2101
US

IV. Provider business mailing address

11811 GUY R BREWER BLVD
JAMAICA NY
11434-2101
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 877-806-9291
Mailing address:
  • Phone: 718-945-7150
  • Fax: 877-806-9291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number207757
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: