Provider Demographics
NPI:1316028590
Name:KOTHA, SUDHARANI SUBBA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUDHARANI
Middle Name:SUBBA
Last Name:KOTHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KOTHA
Other - Middle Name:SUBBA
Other - Last Name:SUDHARANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:609 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4540
Mailing Address - Country:US
Mailing Address - Phone:516-489-8888
Mailing Address - Fax:516-489-6262
Practice Address - Street 1:609 FULTON AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4540
Practice Address - Country:US
Practice Address - Phone:516-489-8888
Practice Address - Fax:516-489-6262
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207757208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01847841Medicaid