Provider Demographics
NPI:1215971718
Name:KOTALA, STANLEY HERBERT
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:HERBERT
Last Name:KOTALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WARD DRIVE
Mailing Address - Street 2:PO BOX 267
Mailing Address - City:CLAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16625-9742
Mailing Address - Country:US
Mailing Address - Phone:814-239-2211
Mailing Address - Fax:814-239-8116
Practice Address - Street 1:365 WARD DRIVE
Practice Address - Street 2:
Practice Address - City:CLAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16625-9742
Practice Address - Country:US
Practice Address - Phone:814-239-2211
Practice Address - Fax:814-239-8116
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044888L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA076155OtherBLUE SHIELD
PA01271189Medicaid
PA076155OtherBLUE SHIELD
PA710900E0WMedicare PIN