Healthcare Provider Details

I. General information

NPI: 1568852929
Provider Name (Legal Business Name): DR. LEZLIE KOTLYAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 10/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13278 HEATHER RIDGE LOOP
FORT MYERS FL
33966-7511
US

IV. Provider business mailing address

13278 HEATHER RIDGE LOOP
FORT MYERS FL
33966
US

V. Phone/Fax

Practice location:
  • Phone: 239-281-0364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS58359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: