Provider Demographics
NPI:1164788709
Name:KOTHAPALLI, VANITHA DORAIRAJAN (MD)
Entity Type:Individual
Prefix:
First Name:VANITHA
Middle Name:DORAIRAJAN
Last Name:KOTHAPALLI
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 1:1501 KINGS HWY
Mailing Address - Street 2:DEPT. OF PSYCHAITRY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6619
Mailing Address - Fax:318-675-6148
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPT. OF PSYCHAITRY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6619
Practice Address - Fax:318-675-6148
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA3004962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program