Provider Demographics
NPI:1760545503
Name:VIJAY C KATUKOTA, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:VIJAY C KATUKOTA, A MEDICAL CORPORATION
Other - Org Name:VIJAY C. KATUKOTA,, A MEDICAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:CHANDRA
Authorized Official - Last Name:KATUKOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-623-9900
Mailing Address - Street 1:1177 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3028
Mailing Address - Country:US
Mailing Address - Phone:909-623-9900
Mailing Address - Fax:909-623-1993
Practice Address - Street 1:1177 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3028
Practice Address - Country:US
Practice Address - Phone:909-623-9900
Practice Address - Fax:909-623-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38343207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383430Medicaid
CAA38343Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO
CAC35490Medicare UPIN