Provider Demographics
NPI:1710950100
Name:KOTZAN, CAROL ANNE (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:KOTZAN
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 1:53 STRATHAM CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-6908
Mailing Address - Country:US
Mailing Address - Phone:815-455-7200
Mailing Address - Fax:815-455-9256
Practice Address - Street 1:525 E CONGRESS PARKWAY SUITE 250
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6258
Practice Address - Country:US
Practice Address - Phone:815-455-7200
Practice Address - Fax:815-455-9256
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076689Medicaid
IL5632272OtherBCBS
ILPENDINGMedicare UPIN
IL036076689Medicaid
IL5632272OtherBCBS
IL202118Medicare UPIN
IL202107Medicare UPIN
ILK48394/LAKEMedicare UPIN
B54296Medicare UPIN