Provider Demographics
NPI:1154326429
Name:KOTTER, WAYNE ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
Last Name:KOTTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 S 1950 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-2402
Mailing Address - Country:US
Mailing Address - Phone:801-773-6565
Mailing Address - Fax:801-774-6967
Practice Address - Street 1:5320 S 1950 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2402
Practice Address - Country:US
Practice Address - Phone:801-773-6565
Practice Address - Fax:801-774-6967
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0511213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT480157299OtherRAILROAD MEDICARE
UT000064444Medicare PIN
UT480157299OtherRAILROAD MEDICARE