Healthcare Provider Details

I. General information

NPI: 1821034976
Provider Name (Legal Business Name): DAVID E. KOTUN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 USF LAUREL DR
TAMPA FL
33612-6601
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-7770
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-2201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: