Provider Demographics
NPI:1457447872
Name:CHANDRASEKHARA, KOTA (MD)
Entity Type:Individual
Prefix:
First Name:KOTA
Middle Name:
Last Name:CHANDRASEKHARA
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:DE
Mailing Address - Zip Code:19940-0157
Mailing Address - Country:US
Mailing Address - Phone:410-896-3693
Mailing Address - Fax:410-896-3698
Practice Address - Street 1:9315 OCEAN HWY
Practice Address - Street 2:SUITE B
Practice Address - City:DELMAR
Practice Address - State:MD
Practice Address - Zip Code:21875-2339
Practice Address - Country:US
Practice Address - Phone:410-896-3693
Practice Address - Fax:410-896-3698
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25091207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B68850Medicare ID - Type Unspecified
B68850Medicare UPIN