Provider Demographics
NPI:1689622714
Name:KOTA, CHANDRASEKHAR (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRASEKHAR
Middle Name:
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 1:1012 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3468
Mailing Address - Country:US
Mailing Address - Phone:814-333-2001
Mailing Address - Fax:814-333-6236
Practice Address - Street 1:1012 WATER ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3468
Practice Address - Country:US
Practice Address - Phone:814-337-8532
Practice Address - Fax:814-333-1025
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.064554207RE0101X
PAMD426736207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA003359380OtherHIGHMARK BLUE CROSS BLUE SHIELD
OH0055992Medicaid
PA1013266190002Medicaid
OH000000736969OtherANTHEM
OH000000737001OtherANTHEM
PAP01667340OtherRAILROAD MEDICARE
WV3810021787Medicaid
OH0055992Medicaid
PA093036KAMMedicare PIN
PAP01667340OtherRAILROAD MEDICARE