Provider Demographics
NPI:1487876512
Name:KOTYK, TODD J (PT)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:KOTYK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 E PIKE ST
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-1765
Mailing Address - Country:US
Mailing Address - Phone:724-745-5646
Mailing Address - Fax:724-745-6062
Practice Address - Street 1:153 EAST PIKE ST.
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-1765
Practice Address - Country:US
Practice Address - Phone:724-745-5646
Practice Address - Fax:724-745-6062
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-009765-L225100000X
WV2484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAKO425781OtherHIGHMARK BLUE SHIELD
5139764OtherAETNA PIN PPO PRODUCTS
11513356OtherCAQH PROVIDER ID
1279105OtherAETNA HMO PROVIDER NUMBER
11513356OtherCAQH PROVIDER ID