Provider Demographics
NPI:1174560148
Name:KOTTAPALLI, AJAY K (MD)
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:K
Last Name:KOTTAPALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5287
Mailing Address - Fax:740-446-5854
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5287
Practice Address - Fax:740-446-5854
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-4335207R00000X
WV18873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000185257OtherUNISON MEDICAID
000000198554OtherANTHEM BCBS
OH310917085049OtherOH MEDICAID CARESOURCE
OH2088753OtherMOLINA MEDICAID
000357167OtherMOUNTAIN STATE BCBS
110192508OtherRR MEDICARE
WV0080104000Medicaid
OH2088753Medicaid
OH000000185257OtherUNISON MEDICAID
110192508OtherRR MEDICARE
G44723Medicare UPIN