Provider Demographics
NPI:1851348247
Name:KOTLYAROV, EDUARD VOLFOVITCH (MD)
Entity Type:Individual
Prefix:MR
First Name:EDUARD
Middle Name:VOLFOVITCH
Last Name:KOTLYAROV
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 32627
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-0627
Mailing Address - Country:US
Mailing Address - Phone:866-744-1452
Mailing Address - Fax:586-412-4101
Practice Address - Street 1:1375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1350
Practice Address - Country:US
Practice Address - Phone:810-667-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010327002085N0904X, 2085R0202X
MDD00260592085N0904X, 2085R0202X
MI43010617442085N0904X, 2085R0202X
DCMD114512085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2965193Medicaid
MI300049506OtherRRMC
MI310D460020OtherBCBS GROUP PIN
MI3006399421OtherBCBS PIN #
MICA5318OtherMEDICARE RR GROUP PIN
MI2965228Medicaid
MI0F36125014Medicare PIN
MI2965228Medicaid
MI3006399421OtherBCBS PIN #