Healthcare Provider Details

I. General information

NPI: 1497791347
Provider Name (Legal Business Name): JOAN KOTUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD VA 116A
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

150 MUIR RD BOX 116A
MARTINEZ CA
94553-4668
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-2105
  • Fax: 925-372-2830
Mailing address:
  • Phone: 925-372-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301045458
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG87931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: