Healthcare Provider Details

I. General information

NPI: 1508994484
Provider Name (Legal Business Name): CHRISTOPHER KOTH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30387 THREE NOTCH ROAD CHARLOTTE HALL
CHARLOTTE HALL MD
20622-3183
US

IV. Provider business mailing address

PO BOX 398 CHARLOTTE HALL
CHARLOTTE HALL MD
20622-0398
US

V. Phone/Fax

Practice location:
  • Phone: 301-884-0331
  • Fax: 301-472-4388
Mailing address:
  • Phone: 301-884-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19020
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: