Provider Demographics
NPI:1467078857
Name:KOTHA, ANIRUDH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIRUDH
Middle Name:
Last Name:KOTHA
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 1:22151 MOROSS RD
Mailing Address - Street 2:STE 214
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:STE 214
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-343-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2022-02-01
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2022-02-01
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program