Healthcare Provider Details

I. General information

NPI: 1669679700
Provider Name (Legal Business Name): VIJENDRA KOTTURI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

PO BOX 59028
RENTON WA
98058-2028
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-3220
  • Fax: 253-395-1954
Mailing address:
  • Phone: 425-251-5110
  • Fax: 425-793-7458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60051023
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60051023
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA09045100
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA09045100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: