MEDICARE: SHASHANK KOTAKONDA MB;BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD458422	PA
2	208M00000X	Hospitalist Physician	MD458422	PA

General Provider Information

NPI Number	:	1467892927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHASHANK KOTAKONDA MB;BS

Provider Business Mailing Address
First Line	:	100 NORTH ACADEMY AVENUE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-4903
Country	:	US
Telephone Number	:	570-271-6144
Fax Number	:	570-271-6578

Provider Business Practice Location Address
First Line	:	1000 E MOUNTAIN BLVD
Second Line	:
City	:	WILKES BARRE
State	:	PA
Zip	:	18711-3539
Country	:	US
Telephone Number	:	570-808-7399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2013
Last Update Date	:	09/29/2016

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