Provider Demographics
NPI:1346549219
Name:KOTOB, FAYEZ (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:FAYEZ
Middle Name:
Last Name:KOTOB
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-0846
Mailing Address - Country:US
Mailing Address - Phone:810-230-7400
Mailing Address - Fax:810-230-7440
Practice Address - Street 1:5050 VILLA LINDE PKWY STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3436
Practice Address - Country:US
Practice Address - Phone:810-230-7400
Practice Address - Fax:810-230-7440
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098964208VP0014X, 207L00000X, 207LH0002X, 207LA0401X, 207LP3000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine