Provider Demographics
NPI:1790085454
Name:KOTLER, JUSTIN A (MS, RD, CDE)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:A
Last Name:KOTLER
Suffix:
Gender:M
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 E LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4510
Mailing Address - Country:US
Mailing Address - Phone:410-409-6992
Mailing Address - Fax:
Practice Address - Street 1:867 E LOMBARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4510
Practice Address - Country:US
Practice Address - Phone:410-409-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD967514133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered