Provider Demographics
NPI:1629239942
Name:THOTTAKARA, JOHN GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GEORGE
Last Name:THOTTAKARA
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 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:UT SOUTHWESTERN MEDICAL CENTER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9055
Mailing Address - Country:US
Mailing Address - Phone:214-648-2733
Mailing Address - Fax:214-648-9207
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:UT SOUTHWESTERN MEDICAL CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9055
Practice Address - Country:US
Practice Address - Phone:214-648-2733
Practice Address - Fax:214-648-9207
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN0506208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203586701Medicaid