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 1:6100 NORTH DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6950
Practice Address - Country:US
Practice Address - Phone:850-471-2377
Practice Address - Fax:850-471-9975
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62757174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL590 51780OtherBCBS OF ALA
FL4314144OtherAETNA
FL7618346003OtherCIGNA PPO
AL009900475OtherMEDICAID ALA
FL42544OtherBCBS OF FLORIDA
FL040016528OtherUHC MCR RR
FL253548300Medicaid
FL42544OtherBCBS OF FLORIDA
FL253548300Medicaid