Provider Demographics
NPI:1063506434
Name:KOTLA, REVATHI (MD)
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:
Last Name:KOTLA
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 1:61 JOANNA WAY
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-3206
Mailing Address - Country:US
Mailing Address - Phone:973-758-1650
Mailing Address - Fax:
Practice Address - Street 1:61 JOANNA WAY
Practice Address - Street 2:
Practice Address - City:SHORT HILLS
Practice Address - State:NJ
Practice Address - Zip Code:07078-3206
Practice Address - Country:US
Practice Address - Phone:973-758-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA325921207RN0300X
NJMA64664207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7697805Medicaid
NJ7697805Medicaid
NJG81577Medicare UPIN