Healthcare Provider Details

I. General information

NPI: 1790085454
Provider Name (Legal Business Name): JUSTIN A KOTLER MS, RD, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 E LOMBARD ST
BALTIMORE MD
21202-4510
US

IV. Provider business mailing address

867 E LOMBARD ST
BALTIMORE MD
21202-4510
US

V. Phone/Fax

Practice location:
  • Phone: 410-409-6992
  • Fax:
Mailing address:
  • Phone: 410-409-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number967514
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: