Provider Demographics
NPI:1720055353
Name:KOTA, ANJANI (MD)
Entity Type:Individual
Prefix:DR
First Name:ANJANI
Middle Name:
Last Name:KOTA
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 1:100 N BELLE MEAD AVE STE D
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3530
Mailing Address - Country:US
Mailing Address - Phone:631-751-8905
Mailing Address - Fax:631-751-8908
Practice Address - Street 1:100 N BELLE MEAD AVE STE D
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3530
Practice Address - Country:US
Practice Address - Phone:631-751-8905
Practice Address - Fax:631-751-8908
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222728-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021AQ2Medicare ID - Type Unspecified
NYH91854Medicare UPIN