Provider Demographics
NPI:1821484601
Name:GEORGE, MATTHEW KOTTACKAL (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KOTTACKAL
Last Name:GEORGE
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 1:6421 BURBERRY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7807
Mailing Address - Country:US
Mailing Address - Phone:518-391-0548
Mailing Address - Fax:
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2425
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1663812086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery