Provider Demographics
NPI:1598287328
Name:KOTHURU, CHANDRASEKHAR (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRASEKHAR
Middle Name:
Last Name:KOTHURU
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 640
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0640
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:22590 SHADY CT
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-5009
Practice Address - Country:US
Practice Address - Phone:810-262-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD91038207R00000X
MI4301113156390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0091038OtherSTATE LICENSE