Provider Demographics
NPI:1508994484
Name:KOTH, CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:KOTH
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:PO BOX 398
Mailing Address - Street 2:CHARLOTTE HALL
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622-0398
Mailing Address - Country:US
Mailing Address - Phone:301-884-0331
Mailing Address - Fax:
Practice Address - Street 1:30387 THREE NOTCH ROAD
Practice Address - Street 2:CHARLOTTE HALL
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-3183
Practice Address - Country:US
Practice Address - Phone:301-884-0331
Practice Address - Fax:301-472-4388
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD60728701OtherBCBS
MD403877100Medicaid
MD4380001OtherFEDERAL BCBS
MD7261400OtherAETNA
MD7261400OtherAETNA
MD60728701OtherBCBS