Provider Demographics
NPI:1295772077
Name:KOT, MARK ROBERT (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:KOT
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 1:609 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3051
Mailing Address - Country:US
Mailing Address - Phone:631-204-9600
Mailing Address - Fax:631-204-9606
Practice Address - Street 1:609 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-3051
Practice Address - Country:US
Practice Address - Phone:631-204-9600
Practice Address - Fax:631-204-9606
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181198208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEM721Medicare ID - Type UnspecifiedGROUP MCR NUMBER
NY98H241Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
NYF65613Medicare UPIN