Healthcare Provider Details

I. General information

NPI: 1649385733
Provider Name (Legal Business Name): JAGAN KOTHAPALLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2091 LANGHORNE RD
LYNCHBURG VA
24501
US

IV. Provider business mailing address

2140 KINGSLEY AVE STE 10
ORANGE PARK FL
32073-5129
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-3954
  • Fax: 434-947-5944
Mailing address:
  • Phone: 904-529-5252
  • Fax: 904-529-5253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME115829
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: