Provider Demographics
NPI:1780674432
Name:KOTTA, SHRIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SHRIDHAR
Middle Name:
Last Name:KOTTA
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 1:512 VICTORIA LN
Mailing Address - Street 2:SUITE #4
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-3226
Mailing Address - Country:US
Mailing Address - Phone:956-421-5207
Mailing Address - Fax:956-421-5238
Practice Address - Street 1:512 VICTORIA LANE
Practice Address - Street 2:SUITE #4
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-3207
Practice Address - Country:US
Practice Address - Phone:956-421-5207
Practice Address - Fax:956-421-5238
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1511207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101346801Medicaid
TX82181KMedicare ID - Type Unspecified
TX101346801Medicaid