Healthcare Provider Details

I. General information

NPI: 1740336429
Provider Name (Legal Business Name): GREGORY RAPHAEL KOTNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6116 E WARREN AVE
DENVER CO
80222-5703
US

IV. Provider business mailing address

6116 E WARREN AVE
DENVER CO
80222-5703
US

V. Phone/Fax

Practice location:
  • Phone: 303-512-2299
  • Fax:
Mailing address:
  • Phone: 303-512-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101252050
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberDR.0050096
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: