Provider Demographics
NPI:1922090646
Name:KOTLARZ, JACK PETER (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:PETER
Last Name:KOTLARZ
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 1:6100 NORTH DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6950
Mailing Address - Country:US
Mailing Address - Phone:850-471-2377
Mailing Address - Fax:850-471-9975
Practice Address - Street 1:1253 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2201
Practice Address - Country:US
Practice Address - Phone:779-696-9201
Practice Address - Fax:815-397-9667
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62757174400000X, 207Y00000X
MO2024013411207Y00000X
IL036170362207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No174400000XOther Service ProvidersSpecialist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4314144OtherAETNA
FL7618346003OtherCIGNA PPO
AL009900475OtherMEDICAID ALA
FL040016528OtherUHC MCR RR
AL590 51780OtherBCBS OF ALA
FL253548300Medicaid
FL42544OtherBCBS OF FLORIDA
FL42544OtherBCBS OF FLORIDA
FL253548300Medicaid