Individual
DR. VIJAYA GOPAL KOTHA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
215 NORTH AVE, MOUNT CLEMENS, MI 48043-1716
(313) 580-6760
Mailing address
11900 E TWELVE MILE RD, SUITE 111, WARREN, MI 48093-3472
(586) 573-5300
(586) 573-5304
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
4301058577
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
26OE011140
BCBS
—
05
—
4224674
—
MI
Enumeration date
08/13/2006
Last updated
03/31/2021
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