Provider Demographics
NPI:1669996658
Name:KOTAPURI, SUNANDA
Entity type:Individual
Prefix:
First Name:SUNANDA
Middle Name:
Last Name:KOTAPURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 N CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-8095
Mailing Address - Country:US
Mailing Address - Phone:985-446-6381
Mailing Address - Fax:985-446-5992
Practice Address - Street 1:931 N CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-8095
Practice Address - Country:US
Practice Address - Phone:985-446-6381
Practice Address - Fax:985-446-5992
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA324292207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program