Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RN0300X | Nephrologist | 325921 | LA |
Y | 207RN0300X | Nephrologist | MA64664 | NJ |
NPI | 1063506434 |
---|---|
Provider Name | Revathi Kotla |
First Address | Short Hills, NJ 07078-3206 |
Second Address | Short Hills, NJ 07078-3206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 26/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7697805 | (05) | NJ |
G81577 | (02) | NJ |