1588667901 NPI number — DR. KOTESHWAR R TELUKUNTLA MD

Table of content: ANGELA E TRACY LPCC (NPI 1396107835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588667901 NPI number — DR. KOTESHWAR R TELUKUNTLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TELUKUNTLA
Provider First Name:
KOTESHWAR
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588667901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102222
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-2222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-8200
Provider Business Mailing Address Fax Number:
239-278-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 MANATEE AVE W
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34205-2557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-792-1881
Provider Business Practice Location Address Fax Number:
941-795-3924
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0000X , with the licence number:  ME72534 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: ME72534 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 259061100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00387326 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 259061100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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