Healthcare Provider Details

I. General information

NPI: 1760565378
Provider Name (Legal Business Name): MOHAMMAD H KOTAKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PLAZA DR SUIT 5
MISSION TX
78572-6049
US

IV. Provider business mailing address

900 PLAZA DR SUIT 5
MISSION TX
78572-6049
US

V. Phone/Fax

Practice location:
  • Phone: 956-583-0095
  • Fax: 956-583-2118
Mailing address:
  • Phone: 956-583-0095
  • Fax: 956-583-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK0877
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberK0877
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: