Provider Demographics
NPI:1366572000
Name:KOTH, KATHLEEN A (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:KOTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1997
Mailing Address - Street 2:M5 B510
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1997
Mailing Address - Country:US
Mailing Address - Phone:414-266-4920
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:FIFTH FLOOR, SUITE 510
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53989-0212084P0804X
MDH00658002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366572000Medicaid