Provider Demographics
NPI:1700946340
Name:KOTLAR, PETRUSIA G (DC)
Entity Type:Individual
Prefix:DR
First Name:PETRUSIA
Middle Name:G
Last Name:KOTLAR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 5TH AVE
Mailing Address - Street 2:SUITE 2111
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:212-599-2554
Mailing Address - Fax:212-599-2554
Practice Address - Street 1:501 5TH AVE
Practice Address - Street 2:STE 2111
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:212-599-2554
Practice Address - Fax:212-599-2554
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0039241111N00000X
NJ38MC00282800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X68791Medicare ID - Type Unspecified