Provider Demographics
NPI:1588899041
Name:KOTARA, SUSSANN GRACE (MD)
Entity type:Individual
Prefix:MRS
First Name:SUSSANN
Middle Name:GRACE
Last Name:KOTARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6309
Mailing Address - Country:US
Mailing Address - Phone:210-865-7776
Mailing Address - Fax:
Practice Address - Street 1:3501 MILLS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6309
Practice Address - Country:US
Practice Address - Phone:210-865-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-00354632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry