Provider Demographics
NPI:1639172091
Name:KOTYLO, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KOTYLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-2047
Mailing Address - Country:US
Mailing Address - Phone:317-889-8452
Mailing Address - Fax:
Practice Address - Street 1:411 S OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2047
Practice Address - Country:US
Practice Address - Phone:317-889-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38760207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100360620Medicaid
IN000000085801OtherANTHEM PROVIDER NUMBER
KY64077415Medicaid
KYE42534Medicare UPIN
IN220015304Medicare PIN
IN824330QQQQMedicare PIN
KY0075422Medicare PIN