Provider Demographics
NPI:1306814660
Name:KATLIC, KERRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:L
Last Name:KATLIC
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 1:2067 FAIRPORT NINE MILE PT RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1753
Mailing Address - Country:US
Mailing Address - Phone:585-922-0460
Mailing Address - Fax:585-922-0470
Practice Address - Street 1:2067 FAIRPORT NINE MILE PT RD
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1753
Practice Address - Country:US
Practice Address - Phone:585-922-0460
Practice Address - Fax:585-922-0470
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146679208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00762047Medicaid
NYE47288Medicare UPIN
NY00762047Medicaid
NYBB5236Medicare PIN