Healthcare Provider Details

I. General information

NPI: 1588899041
Provider Name (Legal Business Name): SUSSANN GRACE KOTARA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 MILLS AVE
AUSTIN TX
78731-6309
US

IV. Provider business mailing address

3501 MILLS AVE
AUSTIN TX
78731-6309
US

V. Phone/Fax

Practice location:
  • Phone: 210-865-7776
  • Fax:
Mailing address:
  • Phone: 210-865-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberBP1-0035463
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: