Healthcare Provider Details

I. General information

NPI: 1255577581
Provider Name (Legal Business Name): CARLA J KOTSIFAKIS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 05/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10304 TIMBERLAKE CT
OCEAN CITY MD
21842-8837
US

IV. Provider business mailing address

10304 TIMBERLAKE CT
OCEAN CITY MD
21842-8837
US

V. Phone/Fax

Practice location:
  • Phone: 410-251-8224
  • Fax: 410-213-7195
Mailing address:
  • Phone: 410-251-8224
  • Fax: 410-213-7195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0000548
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0001667
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: