Healthcare Provider Details

I. General information

NPI: 1598568958
Provider Name (Legal Business Name): JACOB LOUIS KOTLIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

18 RICHARDSON RD
BELMONT MA
02478-3954
US

V. Phone/Fax

Practice location:
  • Phone: 617-755-5075
  • Fax:
Mailing address:
  • Phone: 617-755-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: