Provider Demographics
NPI:1255307617
Name:KOTTKE, THOMAS E (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:KOTTKE
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 1:640 JACKSON ST
Mailing Address - Street 2:MAIL STOP 11102H
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-5175
Mailing Address - Fax:651-254-1603
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MC 11102H
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-5175
Practice Address - Fax:651-254-1603
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24324207RC0000X
WI47187-0Z0207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN363773500Medicaid
060001881Medicare ID - Type Unspecified
MN363773500Medicaid