Provider Demographics
NPI:1093730814
Name:KOTHA, PURUSHOTHAM (MD)
Entity type:Individual
Prefix:
First Name:PURUSHOTHAM
Middle Name:
Last Name:KOTHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8860 CENTER DR
Mailing Address - Street 2:#400
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3068
Mailing Address - Country:US
Mailing Address - Phone:619-229-1995
Mailing Address - Fax:
Practice Address - Street 1:8860 CENTER DR
Practice Address - Street 2:#400
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3068
Practice Address - Country:US
Practice Address - Phone:619-229-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41538207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099230Medicaid
CAGR0099230Medicaid
CAA29404Medicare UPIN