Provider Demographics
NPI:1740336429
Name:KOTNIS, GREGORY RAPHAEL (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:RAPHAEL
Last Name:KOTNIS
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 1:6116 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5703
Mailing Address - Country:US
Mailing Address - Phone:303-512-2299
Mailing Address - Fax:
Practice Address - Street 1:6116 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5703
Practice Address - Country:US
Practice Address - Phone:303-512-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252050207ZP0102X
CODR.0050096207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
CO99158752Medicaid
VAPENDINGMedicaid
CO99158752Medicaid