Provider Demographics
NPI:1063477834
Name:KOTULA, RUDOLF J (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLF
Middle Name:J
Last Name:KOTULA
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:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:10060 REGENCY CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3732
Practice Address - Country:US
Practice Address - Phone:402-354-1530
Practice Address - Fax:402-354-1535
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43587174400000X
NE21269207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1063477834Medicaid
NE47068731742Medicaid
NE099099032Medicare UPIN