Provider Demographics
NPI:1821271362
Name:DRS MORTON DAVIS DR. MICHAEL KOTLICKY DR MARSHA KOTLICKY OPTOMETRISTS
Entity Type:Organization
Organization Name:DRS MORTON DAVIS DR. MICHAEL KOTLICKY DR MARSHA KOTLICKY OPTOMETRISTS
Other - Org Name:DR. MARSHA KOTLICKY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BYRNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-829-1910
Mailing Address - Street 1:164 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6279
Mailing Address - Country:US
Mailing Address - Phone:301-829-1910
Mailing Address - Fax:301-865-1973
Practice Address - Street 1:164 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6279
Practice Address - Country:US
Practice Address - Phone:301-829-1910
Practice Address - Fax:301-865-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDAO821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT31042Medicare UPIN
MD371LMedicare PIN