Provider Demographics
NPI:1487630430
Name:KOTLARCZYK, GREGORY GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GEORGE
Last Name:KOTLARCZYK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 20247
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34204
Mailing Address - Country:US
Mailing Address - Phone:941-756-5555
Mailing Address - Fax:941-756-5556
Practice Address - Street 1:9020 58TH DR EAST
Practice Address - Street 2:STE 102
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:941-756-5555
Practice Address - Fax:941-756-5556
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
64039XMedicare PIN
V08907Medicare UPIN