Healthcare Provider Details

I. General information

NPI: 1093889024
Provider Name (Legal Business Name): MICHAEL KOTLICKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8827 COLUMBIA 100 PKWY STE 3 THE SIGNATURE CENTRE
COLUMBIA MD
21045-2178
US

IV. Provider business mailing address

8827 COLUMBIA 100 PKWY STE 3 THE SIGNATURE CENTRE
COLUMBIA MD
21045-2178
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-5808
  • Fax: 410-730-5893
Mailing address:
  • Phone: 410-730-5808
  • Fax: 410-730-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTA0750
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: