Healthcare Provider Details

I. General information

NPI: 1174745731
Provider Name (Legal Business Name): BARRY MICHAEL KOTLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 LAKE EDEN DRIVE
BOYNTON BEACH FL
33435-8666
US

IV. Provider business mailing address

67 LAKE EDEN DRIVE
BOYNTON BEACH FL
33435-8666
US

V. Phone/Fax

Practice location:
  • Phone: 561-742-3244
  • Fax: 561-742-3245
Mailing address:
  • Phone: 561-742-3244
  • Fax: 561-742-3245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME82765
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME82765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: