Provider Demographics
NPI:1205363454
Name:KOTLYAR MEDICAL PC
Entity type:Organization
Organization Name:KOTLYAR MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VITALY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTLYAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-862-5558
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0270
Mailing Address - Country:US
Mailing Address - Phone:631-264-2035
Mailing Address - Fax:631-264-1418
Practice Address - Street 1:369 LEXINGTON AVE RM 800
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6536
Practice Address - Country:US
Practice Address - Phone:631-264-2030
Practice Address - Fax:631-264-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-18
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263221207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty