Provider Demographics
NPI:1891733135
Name:REDDY, KOTA R (MD)
Entity Type:Individual
Prefix:
First Name:KOTA
Middle Name:R
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-903-0144
Mailing Address - Fax:770-903-0145
Practice Address - Street 1:6330 PRIMROSE HILL CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4544
Practice Address - Country:US
Practice Address - Phone:770-903-0144
Practice Address - Fax:770-903-0145
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046479207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000809168DMedicaid
GA1609816123OtherGEORGIA CLINIC PC NPI # FOR GROUP
GA000809168BMedicaid
GA000809168CMedicaid
GA000809168BMedicaid
06BDHZDMedicare PIN