Provider Demographics
NPI:1457455628
Name:KOTHAPALLI, MANJULA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJULA
Middle Name:
Last Name:KOTHAPALLI
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 1:304 CAMBERLY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:337-261-0397
Mailing Address - Fax:
Practice Address - Street 1:2100 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501
Practice Address - Country:US
Practice Address - Phone:337-261-0734
Practice Address - Fax:337-261-5471
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10034R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1977322Medicaid
LA1977322Medicaid
LAD50321Medicare UPIN