Provider Demographics
NPI:1346206679
Name:KOOTZ, MARK ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:KOOTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 MALCOLM DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6174
Mailing Address - Country:US
Mailing Address - Phone:410-751-7930
Mailing Address - Fax:
Practice Address - Street 1:6190 GEORGETOWN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6460
Practice Address - Country:US
Practice Address - Phone:410-552-4235
Practice Address - Fax:410-552-4248
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36948OtherJHHC
MD382668OtherMAMSI
MD4368142OtherAETNA
MD023348001Medicaid
MD53024404OtherBCBS
MD3201864OtherAETNA
4761-0101OtherBCBS
MD216566Medicare ID - Type Unspecified