Healthcare Provider Details

I. General information

NPI: 1932192572
Provider Name (Legal Business Name): RONALD W. COTLIAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13420 NEWPORT AVE SUITE G
TUSTIN CA
92780-3745
US

IV. Provider business mailing address

13420 NEWPORT AVE SUITE G
TUSTIN CA
92780-3745
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-0061
  • Fax: 714-731-0164
Mailing address:
  • Phone: 714-731-0061
  • Fax: 714-731-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG25069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: