Healthcare Provider Details

I. General information

NPI: 1336438704
Provider Name (Legal Business Name): JAMES DAVID KOTICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 LAKEFRONT DR UNIT 202
SARASOTA FL
34240-1637
US

IV. Provider business mailing address

PO BOX 3725
AUGUSTA GA
30914-3725
US

V. Phone/Fax

Practice location:
  • Phone: 941-822-8955
  • Fax: 941-822-8684
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-868-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME121445
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME121445
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: