Provider Demographics
NPI:1669466009
Name:KOTZ, KENNETH WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLIAM
Last Name:KOTZ
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-3000
Practice Address - Fax:910-667-9758
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101082207RH0003X, 207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669466009Medicaid
NC8912948Medicaid
SCQ0108NMedicaid
NC830007631OtherRAILROAD MEDICARE
NC89129V8Medicaid
NCNC7751AMedicare PIN
NC8912948Medicaid
NC2288817Medicare PIN