Provider Demographics
NPI:1821416645
Name:KOTLOVE, MATTHEW JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JACOB
Last Name:KOTLOVE
Suffix:
Gender:M
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:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-301-4000
Mailing Address - Fax:859-301-4001
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-4000
Practice Address - Fax:859-301-4001
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.024319207R00000X
OH35.130665207RH0003X, 207R00000X
KY54040207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology