Provider Demographics
NPI:1740386176
Name:KOTULSKI, JEFFREY JOHN (DO)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JOHN
Last Name:KOTULSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 TETON LANE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-388-7488
Mailing Address - Fax:507-388-5680
Practice Address - Street 1:45 TETON LANE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-388-7488
Practice Address - Fax:507-388-5680
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37416204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN560320000Medicaid
MN120000066Medicare ID - Type Unspecified
F63604Medicare UPIN