Provider Demographics
NPI:1790764249
Name:KOTLOVE, DENNIS J (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:KOTLOVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LYON PL
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2586
Mailing Address - Country:US
Mailing Address - Phone:315-713-6220
Mailing Address - Fax:315-393-3873
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-713-6220
Practice Address - Fax:315-393-3873
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1720932085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01194898Medicaid
NYBB0386Medicare PIN