Provider Demographics
NPI:1447221288
Name:KOTTIECH, SAMER (MD)
Entity Type:Individual
Prefix:
First Name:SAMER
Middle Name:
Last Name:KOTTIECH
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 1:601 W 177TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-7152
Mailing Address - Country:US
Mailing Address - Phone:917-453-0744
Mailing Address - Fax:
Practice Address - Street 1:601 W 177TH ST APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-7152
Practice Address - Country:US
Practice Address - Phone:917-453-0744
Practice Address - Fax:646-852-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246854207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000015439Medicaid
NY02911324Medicaid
DEH70304Medicare UPIN
DE010317D78Medicare ID - Type Unspecified