Provider Demographics
NPI:1174713531
Name:KOTLARZ ENT AND FACIAL PLASTIC SURGERY
Entity type:Organization
Organization Name:KOTLARZ ENT AND FACIAL PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:KOTLARZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-471-2377
Mailing Address - Street 1:6100 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6950
Mailing Address - Country:US
Mailing Address - Phone:850-471-2377
Mailing Address - Fax:850-471-9975
Practice Address - Street 1:6100 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6950
Practice Address - Country:US
Practice Address - Phone:850-471-2377
Practice Address - Fax:850-471-9975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3071OtherMEDICARE GROUP
FLE20804Medicare UPIN