Basic Information
| Provider Information | |||||||||
| NPI: | 1194983122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTLA | ||||||||
| FirstName: | VENUMADHAV | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029757007 | ||||||||
| FaxNumber: | 7707181877 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702975700 | ||||||||
| FaxNumber: | 7707181877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | C1-0025235 | DE | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0000X | 79570 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | 44706 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | C1-0025235 | DE | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | 79570 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4236662 | 01 | TN | BCBS | OTHER | 7100070430 | 05 | KY | MEDICAID | 1514694 | 05 | TN | MEDICAID |