Healthcare Provider Details

I. General information

NPI: 1922090646
Provider Name (Legal Business Name): JACK PETER KOTLARZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 N ALPINE RD
ROCKFORD IL
61107-2201
US

IV. Provider business mailing address

6100 NORTH DAVIS HWY
PENSACOLA FL
32504-6950
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-9201
  • Fax: 815-397-9667
Mailing address:
  • Phone: 850-471-2377
  • Fax: 850-471-9975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME62757
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME62757
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2024013411
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036170362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: