Healthcare Provider Details

I. General information

NPI: 1770514713
Provider Name (Legal Business Name): GARY J KOTILA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 OAKFIELD DR
BRANDON FL
33511-4851
US

IV. Provider business mailing address

1336 OAKFIELD DR
BRANDON FL
33511-4851
US

V. Phone/Fax

Practice location:
  • Phone: 813-643-1242
  • Fax: 813-643-1246
Mailing address:
  • Phone: 813-643-1242
  • Fax: 813-643-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301002841
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: