Basic Information
| Provider Information | |||||||||
| NPI: | 1093789968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINIC FOR DIGESTIVE DISEASES, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13203 N 103RD AVE | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239722116 | ||||||||
| FaxNumber: | 6239720521 | ||||||||
| Practice Location | |||||||||
| Address1: | 13203 N 103RD AVE | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239722116 | ||||||||
| FaxNumber: | 6239720521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOTHUR | ||||||||
| AuthorizedOfficialFirstName: | RAMKRISHNA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6239722116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | AZ0805210 | 01 | AZ | BCBS OF AZ/DR BETTINGER | OTHER | 99S007600002 | 01 | AZ | SUN HLTH/DR BELLAPRAVALU | OTHER | 788036 | 05 | AZ | MEDICAID | 250944-02 | 05 | AZ | MEDICAID | 268830-02 | 05 | AZ | MEDICAID | AZ0360800 | 01 | AZ | BCBS/DR PHELPS | OTHER | AZ0727350 | 01 | AZ | BCBS/DR KOTHUR | OTHER | AZ0750990 | 01 | AZ | BCBS DR CHOKSHI | OTHER | 002410-02 | 05 | AZ | MEDICAID | AZ0187530 | 01 | AZ | BCBS/DR PATEL | OTHER | 208604-02 | 05 | AZ | MEDICAID | 855918 | 05 | AZ | MEDICAID | AZ0361810 | 01 | AZ | BCBS/DR BELLAPRAVAL | OTHER |