Healthcare Provider Details

I. General information

NPI: 1174713531
Provider Name (Legal Business Name): KOTLARZ ENT AND FACIAL PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 N DAVIS HWY
PENSACOLA FL
32504-6950
US

IV. Provider business mailing address

6100 N DAVIS HWY
PENSACOLA FL
32504-6950
US

V. Phone/Fax

Practice location:
  • Phone: 850-471-2377
  • Fax: 850-471-9975
Mailing address:
  • Phone: 850-471-2377
  • Fax: 850-471-9975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK P KOTLARZ
Title or Position: PHYSICIAN
Credential: MD
Phone: 850-471-2377