Provider Demographics
NPI:1003884578
Name:WOTKOWICZ, CHAD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:WOTKOWICZ
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 1:81 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2764
Mailing Address - Country:US
Mailing Address - Phone:207-373-6690
Mailing Address - Fax:603-742-3530
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2764
Practice Address - Country:US
Practice Address - Phone:207-373-6690
Practice Address - Fax:603-373-6695
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14482208000000X, 208800000X
MA224790208600000X
MEMD19913208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209883Medicaid
MA2111021Medicaid
MA2111021Medicaid
NH30209883Medicaid