Provider Demographics
NPI:1922112762
Name:LEONID KOTKIN, M.D., P.C.
Entity Type:Organization
Organization Name:LEONID KOTKIN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-783-8875
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:STE. 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-438-6368
Practice Address - Street 1:280 WASHINGTON ST
Practice Address - Street 2:STE. 207
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3511
Practice Address - Country:US
Practice Address - Phone:617-783-8875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA200208861208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9755161Medicaid
MA9755161Medicaid