Provider Demographics
NPI:1184800781
Name:KOTAPOTHULA, SUREKHA VENKATA (MD)
Entity type:Individual
Prefix:
First Name:SUREKHA
Middle Name:VENKATA
Last Name:KOTAPOTHULA
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:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:4TH AND WALNUT STREETS
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6123
Practice Address - Country:US
Practice Address - Phone:717-270-4876
Practice Address - Fax:717-270-3875
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437413207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102327998 0004Medicaid
PA102327998 0004Medicaid