Healthcare Provider Details

I. General information

NPI: 1811269566
Provider Name (Legal Business Name): ERNEST MARVIN KOTLIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SCENIC AVE
BERKELEY CA
94708-1813
US

IV. Provider business mailing address

1555 SCENIC AVE
BERKELEY CA
94708-1813
US

V. Phone/Fax

Practice location:
  • Phone: 510-368-1221
  • Fax: 510-548-1727
Mailing address:
  • Phone: 510-368-1221
  • Fax: 510-548-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCFE28391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: