Healthcare Provider Details

I. General information

NPI: 1255794251
Provider Name (Legal Business Name): ARCHANA SRAVANTHI KOTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-3247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD477059
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: