Provider Demographics
NPI:1225218522
Name:KATUKOTA, VIJAYA K (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:K
Last Name:KATUKOTA
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 1:4295 JURUPA ST
Mailing Address - Street 2:STE 117
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-1430
Mailing Address - Country:US
Mailing Address - Phone:323-550-1920
Mailing Address - Fax:
Practice Address - Street 1:975 SAINT JOHN PL
Practice Address - Street 2:STE A
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4428
Practice Address - Country:US
Practice Address - Phone:323-550-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38220OtherCALIFORNIA LICENSE