Provider Demographics
NPI:1093889024
Name:KOTLICKY, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:KOTLICKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8827 COLUMBIA 100 PKWY STE 3
Mailing Address - Street 2:THE SIGNATURE CENTRE
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2178
Mailing Address - Country:US
Mailing Address - Phone:410-730-5808
Mailing Address - Fax:410-730-5893
Practice Address - Street 1:8827 COLUMBIA 100 PKWY STE 3
Practice Address - Street 2:THE SIGNATURE CENTRE
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2178
Practice Address - Country:US
Practice Address - Phone:410-730-5808
Practice Address - Fax:410-730-5893
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0750152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy