Healthcare Provider Details

I. General information

NPI: 1780156257
Provider Name (Legal Business Name): JONATHAN M KOOTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/08/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W SAMPLE RD STE B
CORAL SPRINGS FL
33065-3936
US

IV. Provider business mailing address

1050 NW 80TH AVE APT 204
MARGATE FL
33063-3020
US

V. Phone/Fax

Practice location:
  • Phone: 954-234-5340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number4013
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: