Provider Demographics
NPI:1467892927
Name:KOTAKONDA, SHASHANK (MB;BS)
Entity Type:Individual
Prefix:
First Name:SHASHANK
Middle Name:
Last Name:KOTAKONDA
Suffix:
Gender:M
Credentials:MB;BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH ACADEMY AVENUE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-3539
Practice Address - Country:US
Practice Address - Phone:570-808-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD458422207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAKO523312Medicare PIN