=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043670490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOTA & KOKA, AMC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2016
-----------------------------------------------------
Last Update Date | 02/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2732 NAVAJO RD SUITE 200
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-7246
-----------------------------------------------------
Fax | 619-825-8250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2732 NAVAJO RD SUITE 200
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-287-7246
-----------------------------------------------------
Fax | 619-825-8250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MR. KRISH R THOTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-287-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | G84603
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | A53526
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------