Provider Demographics
NPI:1992070312
Name:KOOTA, IVAN RONALD (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:RONALD
Last Name:KOOTA
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 1:337 COLLINS TER
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:NY
Mailing Address - Zip Code:13753-1402
Mailing Address - Country:US
Mailing Address - Phone:607-746-8122
Mailing Address - Fax:
Practice Address - Street 1:337 COLLINS TER
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753-1402
Practice Address - Country:US
Practice Address - Phone:607-746-8122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY097360OtherMEDICAL LICENSE NUMBER