Provider Demographics
NPI:1255350278
Name:KOKOTAKIS, EMANUEL JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:JOSEPH
Last Name:KOKOTAKIS
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 1:18101 PRINCE PHILIP DRIVE
Mailing Address - Street 2:MEDSTAR MONTGOMERY MEDICAL CENTER
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832
Mailing Address - Country:US
Mailing Address - Phone:301-774-8882
Mailing Address - Fax:
Practice Address - Street 1:18101 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1514
Practice Address - Country:US
Practice Address - Phone:301-774-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD56030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD326502101Medicaid
MD326502101Medicaid
MDF56894Medicare UPIN