Basic Information
| Provider Information | |||||||||
| NPI: | 1205363454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOTLYAR MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117620270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642035 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Practice Location | |||||||||
| Address1: | 369 LEXINGTON AVE RM 800 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100176536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312642030 | ||||||||
| FaxNumber: | 6312641418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOTLYAR | ||||||||
| AuthorizedOfficialFirstName: | VITALY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9178625558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 263221 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.