Provider Demographics
NPI:1891840872
Name:KOTLOV, MIKHAIL (MD)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:KOTLOV
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 1:1 KALISA WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652
Mailing Address - Country:US
Mailing Address - Phone:201-447-0013
Mailing Address - Fax:201-255-4515
Practice Address - Street 1:1 KALISA WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-447-0013
Practice Address - Fax:201-255-4515
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238660207R00000X
NJ25MA08410200207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine