Provider Demographics
NPI:1659481562
Name:KOTA, SRINIVAS CHAKRAVARTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:CHAKRAVARTHY
Last Name:KOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3256 LAPP LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8350
Mailing Address - Country:US
Mailing Address - Phone:630-378-9785
Mailing Address - Fax:630-378-9836
Practice Address - Street 1:726 S WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5451
Practice Address - Country:US
Practice Address - Phone:630-378-9785
Practice Address - Fax:630-348-9836
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
9932023OtherBCBS
9932023OtherBCBS
G52541Medicare UPIN