Basic Information
| Provider Information | |||||||||
| NPI: | 1568644557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL S KOTTLER MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27688 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015341360 | ||||||||
| FaxNumber: | 8013669883 | ||||||||
| Practice Location | |||||||||
| Address1: | 4568 HIGHLAND DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841174263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014243090 | ||||||||
| FaxNumber: | 8014243091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | KOTTLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8014243090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 1591691205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.