Provider Demographics
NPI:1669679700
Name:KOTTURI, VIJENDRA (MD)
Entity Type:Individual
Prefix:
First Name:VIJENDRA
Middle Name:
Last Name:KOTTURI
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 59028
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-2028
Mailing Address - Country:US
Mailing Address - Phone:425-251-5110
Mailing Address - Fax:425-793-7458
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3220
Practice Address - Fax:253-395-1954
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60051023207R00000X, 208M00000X
NJ25MA09045100208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00927875OtherMEDICARE RAILROAD
WA0272031OtherL&I
WA2002120Medicaid
WAG8896591Medicare PIN