Provider Demographics
NPI:1699773218
Name:KOTTAL, ROY A (M D)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:A
Last Name:KOTTAL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5321
Mailing Address - Country:US
Mailing Address - Phone:319-364-0121
Mailing Address - Fax:319-364-5684
Practice Address - Street 1:1948 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5321
Practice Address - Country:US
Practice Address - Phone:319-364-0121
Practice Address - Fax:319-364-5684
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA286342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1083675Medicaid
IA46599Medicare PIN
IA1083675Medicaid