Provider Demographics
NPI:1912952011
Name:KOT, EGON (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:EGON
Middle Name:
Last Name:KOT
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 CLIFTON AVE.
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011
Mailing Address - Country:US
Mailing Address - Phone:973-772-5457
Mailing Address - Fax:973-772-5457
Practice Address - Street 1:453 CLIFTON AVE.
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011
Practice Address - Country:US
Practice Address - Phone:973-772-5457
Practice Address - Fax:973-772-5457
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00042100156FX1800X
NJ31TD00038900237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0037958Medicaid
NJ1445006Medicaid
NJ4706890001Medicare NSC