Healthcare Provider Details

I. General information

NPI: 1922927219
Provider Name (Legal Business Name): MADHURIMA KOTA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1717
POWELL OH
43065-1717
US

IV. Provider business mailing address

PO BOX 1717
POWELL OH
43065-1717
US

V. Phone/Fax

Practice location:
  • Phone: 614-495-1064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046012089
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: