Healthcare Provider Details

I. General information

NPI: 1093912149
Provider Name (Legal Business Name): CHRISTOPHER DOUGLAS KOTZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 SENN RD BUILDING 55, ROOM 225
SAN DIEGO CA
92136-5029
US

IV. Provider business mailing address

13044 YERBA VALLEY WAY
LAKESIDE CA
92040-1579
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-5454
  • Fax:
Mailing address:
  • Phone: 817-881-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: