Provider Demographics
NPI:1609921782
Name:KOTA, SURESH K (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:K
Last Name:KOTA
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 1:4214 ANDREWS HWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4817
Mailing Address - Country:US
Mailing Address - Phone:432-221-5965
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:432-221-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47025207R00000X
IA35611207R00000X
TXM8095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0749283Medicaid
IA1749283Medicaid
TXM8095OtherTX LIC
IA47568OtherWELLMARK BLUE CROSS
WI34539400Medicaid
IA0749283Medicaid