Provider Demographics
NPI:1093912149
Name:KOTZ, CHRISTOPHER DOUGLAS (IDC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:DOUGLAS
Last Name:KOTZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13044 YERBA VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-1579
Mailing Address - Country:US
Mailing Address - Phone:817-881-8696
Mailing Address - Fax:
Practice Address - Street 1:3325 SENN RD
Practice Address - Street 2:BUILDING 55, ROOM 225
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5029
Practice Address - Country:US
Practice Address - Phone:619-556-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman