Provider Demographics
NPI:1528036118
Name:KOTHAPALLI, SRINIVASA RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVASA
Middle Name:RAO
Last Name:KOTHAPALLI
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 1:2501 JIMMY JOHNSON BOULEVARD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640
Mailing Address - Country:US
Mailing Address - Phone:409-723-6600
Mailing Address - Fax:409-723-6698
Practice Address - Street 1:2501 JIMMY JOHNSON BOULEVARD
Practice Address - Street 2:SUITE 500
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640
Practice Address - Country:US
Practice Address - Phone:409-723-6600
Practice Address - Fax:409-723-6698
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1286207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22015OtherGTPA
060042362OtherPALMETTO GBA
TX135601601Medicaid
060042362OtherPALMETTO GBA
83Z750Medicare ID - Type UnspecifiedMEDICARE