Provider Demographics
NPI:1770794653
Name:KOTTOOR, MINI J
Entity type:Individual
Prefix:
First Name:MINI
Middle Name:J
Last Name:KOTTOOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18730 MARBLEHEAD DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8549
Mailing Address - Country:US
Mailing Address - Phone:248-344-1787
Mailing Address - Fax:
Practice Address - Street 1:18730 MARBLEHEAD DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-8549
Practice Address - Country:US
Practice Address - Phone:248-344-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN33990001Medicare ID - Type Unspecified