Provider Demographics
NPI:1841427747
Name:KOTLYAR, VITALY (MD)
Entity Type:Individual
Prefix:DR
First Name:VITALY
Middle Name:
Last Name:KOTLYAR
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 1:39 PLANTING FIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1818
Mailing Address - Country:US
Mailing Address - Phone:917-862-5558
Mailing Address - Fax:
Practice Address - Street 1:369 LEXINGTON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6536
Practice Address - Country:US
Practice Address - Phone:631-264-2030
Practice Address - Fax:631-264-1418
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY263221-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program