Provider Demographics
NPI:1528279965
Name:KOTICHA, KIRTAN NALIN (MD)
Entity type:Individual
Prefix:
First Name:KIRTAN
Middle Name:NALIN
Last Name:KOTICHA
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 1:1455 E. BERT KOUNS
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-798-4424
Mailing Address - Fax:318-798-4450
Practice Address - Street 1:1455 E BERT KOUN LOOP # 101
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4424
Practice Address - Fax:318-798-4450
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204824207RH0003X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1099881Medicaid
LA1099881Medicaid