Provider Demographics
NPI:1811591712
Name:KOTRA, NAGESWARA R
Entity type:Individual
Prefix:
First Name:NAGESWARA
Middle Name:R
Last Name:KOTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7313 ZION LN
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-7592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 STONEBROOK PKWY
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75036-3008
Practice Address - Country:US
Practice Address - Phone:214-469-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist