Healthcare Provider Details

I. General information

NPI: 1770452583
Provider Name (Legal Business Name): MARTINA KOTRBA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E NORRIS DR STE 1C
OTTAWA IL
61350-1608
US

IV. Provider business mailing address

1204 EMINGTON LN
MINOOKA IL
60447-4542
US

V. Phone/Fax

Practice location:
  • Phone: 815-239-6308
  • Fax:
Mailing address:
  • Phone: 773-590-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number085.011653
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: