Healthcare Provider Details

I. General information

NPI: 1124233846
Provider Name (Legal Business Name): VANI KOTHA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 10/17/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 HOSPITAL PKWY STE 202
BEDFORD TX
76022-5935
US

IV. Provider business mailing address

1615 HOSPITAL PKWY STE 202
BEDFORD TX
76022-5935
US

V. Phone/Fax

Practice location:
  • Phone: 817-786-8686
  • Fax: 866-869-0489
Mailing address:
  • Phone: 817-786-8686
  • Fax: 866-869-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberM6242
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: