Provider Demographics
NPI:1205825312
Name:KOTIA, GODSON G (MD)
Entity Type:Individual
Prefix:
First Name:GODSON
Middle Name:G
Last Name:KOTIA
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 1:1904 E. CHICAGO ROAD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091
Mailing Address - Country:US
Mailing Address - Phone:269-651-7003
Mailing Address - Fax:269-651-8970
Practice Address - Street 1:1904 E. CHICAGO ROAD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091
Practice Address - Country:US
Practice Address - Phone:269-651-7003
Practice Address - Fax:269-651-8970
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGK0783412086S0129X
MI43010783412086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104342471Medicaid
MI4342471Medicaid
MION35760Medicare PIN
MION35760Medicare ID - Type Unspecified
MI104342471Medicaid