Provider Demographics
NPI:1770526584
Name:KOTHA, RAVI (MD)
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:KOTHA
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:PO BOX 827431
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7431
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:HWY 61 SOUTH
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019
Practice Address - Country:US
Practice Address - Phone:904-805-1300
Practice Address - Fax:904-805-1302
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003021689207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO426403OtherHEALTHLINK
MO208824110Medicaid
MO222382593OtherCHAMPUS
MOP00066451OtherRAILROAD MEDICARE
MO947071631OtherMERCY HEALTH
MO124884OtherBLUE CROSS
MO906385198Medicare PIN
MO124884OtherBLUE CROSS
MO906385005Medicare PIN
MO906384740Medicare PIN
MOP00066451OtherRAILROAD MEDICARE
MO906384748Medicare PIN
MO906383209Medicare PIN
MO150050027Medicare PIN
MO208824110Medicaid
MO151980008Medicare PIN