Provider Demographics
NPI:1801980008
Name:KOTTIATH, PRINCE G (MD)
Entity type:Individual
Prefix:DR
First Name:PRINCE
Middle Name:G
Last Name:KOTTIATH
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 1:714 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047
Mailing Address - Country:US
Mailing Address - Phone:267-566-4543
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 72
Practice Address - Street 2:NEW LISBON DEVELOPMENTAL CENTER, HEALTH SERVICES
Practice Address - City:NEW LISBON
Practice Address - State:NJ
Practice Address - Zip Code:08064
Practice Address - Country:US
Practice Address - Phone:609-726-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25 MA07635200207R00000X
PAMD421855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH96593Medicare UPIN