Provider Demographics
NPI:1780651323
Name:KOTA, RAVINDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVINDRA
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 1:40 BRAYTON CT N
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4625
Mailing Address - Country:US
Mailing Address - Phone:631-475-6663
Mailing Address - Fax:631-475-6664
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4855
Practice Address - Country:US
Practice Address - Phone:631-475-6663
Practice Address - Fax:631-475-6664
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221334-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY407I51Medicare ID - Type Unspecified
NYH40807Medicare UPIN