Healthcare Provider Details

I. General information

NPI: 1013756253
Provider Name (Legal Business Name): KRISHNA KOTHAMASU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 KNIGHTS RD
PHILADELPHIA PA
19114-4200
US

IV. Provider business mailing address

10800 KNIGHTS RD
PHILADELPHIA PA
19114-4200
US

V. Phone/Fax

Practice location:
  • Phone: 215-612-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT023494
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: