Healthcare Provider Details

I. General information

NPI: 1881988020
Provider Name (Legal Business Name): HARIKRISHNA KOTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

709 HELMSLEY PL
SOUTHLAKE TX
76092-8641
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-7211
  • Fax:
Mailing address:
  • Phone: 551-556-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number258946
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number258946
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ7904
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: