Provider Demographics
NPI:1063668614
Name:KOTA MEDICAL PC
Entity Type:Organization
Organization Name:KOTA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANGA
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:KOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-759-5812
Mailing Address - Street 1:3630 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5075
Mailing Address - Country:US
Mailing Address - Phone:219-759-5812
Mailing Address - Fax:219-759-5890
Practice Address - Street 1:3630 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5075
Practice Address - Country:US
Practice Address - Phone:219-759-5812
Practice Address - Fax:219-759-5890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038987207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200007810Medicaid
IN200007810Medicaid
IN257990AMedicare PIN