Provider Demographics
NPI:1124197447
Name:KOTHA, VIJAYASIMHA (MD)
Entity Type:Individual
Prefix:MR
First Name:VIJAYASIMHA
Middle Name:
Last Name:KOTHA
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:P.O. BOX 156
Mailing Address - Street 2:312 KING STREET
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1195
Mailing Address - Country:US
Mailing Address - Phone:315-393-1144
Mailing Address - Fax:315-393-1476
Practice Address - Street 1:312 KING STREET
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-393-1144
Practice Address - Fax:315-393-1476
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1140931208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00500587Medicaid
B81224Medicare UPIN
IA0783Medicare ID - Type Unspecified