Provider Demographics
NPI:1275644064
Name:KOTTAHACHCHI, WIJE (MD)
Entity Type:Individual
Prefix:DR
First Name:WIJE
Middle Name:
Last Name:KOTTAHACHCHI
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 1:468 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3143
Mailing Address - Country:US
Mailing Address - Phone:732-442-1820
Mailing Address - Fax:732-442-2918
Practice Address - Street 1:468 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3143
Practice Address - Country:US
Practice Address - Phone:732-442-1820
Practice Address - Fax:732-442-2918
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2442809Medicaid
NJD96866Medicare UPIN