Provider Demographics
NPI:1790894954
Name:KOTHAPALLY, JAYA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:JAYA
Middle Name:REDDY
Last Name:KOTHAPALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 C. SUNSET ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046
Mailing Address - Country:US
Mailing Address - Phone:609-877-0400
Mailing Address - Fax:609-877-3542
Practice Address - Street 1:218 C. SUNSET ROAD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046
Practice Address - Country:US
Practice Address - Phone:609-877-0400
Practice Address - Fax:609-877-3542
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08944000207RE0101X
MO2006012190390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA08944000OtherMEDICAL LICENSE