1801980008 NPI number — DR. PRINCE G KOTTIATH MD

Table of content: KELLY LAUREL LOPEZ CRNA (NPI 1851792584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801980008 NPI number — DR. PRINCE G KOTTIATH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOTTIATH
Provider First Name:
PRINCE
Provider Middle Name:
G
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:
1801980008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 FORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANGHORNE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-566-4543
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROUTE 72
Provider Second Line Business Practice Location Address:
NEW LISBON DEVELOPMENTAL CENTER, HEALTH SERVICES
Provider Business Practice Location Address City Name:
NEW LISBON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-726-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

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: 207R00000X , with the licence number:  25 MA07635200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: MD421855 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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