Provider Demographics
NPI:1700854395
Name:KOTHA, VIJAY KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:KUMAR
Last Name:KOTHA
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 1:33545 CHERRY HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186
Mailing Address - Country:US
Mailing Address - Phone:734-595-1166
Mailing Address - Fax:734-595-6821
Practice Address - Street 1:33545 CHERRY HILL ROAD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186
Practice Address - Country:US
Practice Address - Phone:734-595-1166
Practice Address - Fax:734-595-6821
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47160020208800000X
MI4301089312208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09921Medicare UPIN