Basic Information
| Provider Information | |||||||||
| NPI: | 1396921755 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KOTHA | ||||||||
| FirstName: | SUDHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 168 IRVING AVE | ||||||||
| Address2: | STE 402-A | ||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105734157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149393143 | ||||||||
| FaxNumber: | 9149393120 | ||||||||
| Practice Location | |||||||||
| Address1: | 5980 W 71ST ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462781785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173880800 | ||||||||
| FaxNumber: | 3173880805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 029333 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.