Healthcare Provider Details

I. General information

NPI: 1124197447
Provider Name (Legal Business Name): VIJAYASIMHA KOTHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 KING STREET
OGDENSBURG NY
13669
US

IV. Provider business mailing address

P.O. BOX 156 312 KING STREET
OGDENSBURG NY
13669-1195
US

V. Phone/Fax

Practice location:
  • Phone: 315-393-1144
  • Fax: 315-393-1476
Mailing address:
  • Phone: 315-393-1144
  • Fax: 315-393-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1140931
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: