Provider Demographics
NPI:1326035825
Name:KOTKIN, LEONID (MD)
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:
Last Name:KOTKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:SUITE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-438-6368
Practice Address - Street 1:280 WASHINGTON ST
Practice Address - Street 2:STE. 207
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3511
Practice Address - Country:US
Practice Address - Phone:617-783-8875
Practice Address - Fax:617-782-3367
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA151270208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3159345Medicaid
MAVX1811Medicare PIN
MA3159345Medicaid
MAA21366Medicare PIN