Healthcare Provider Details

I. General information

NPI: 1700038023
Provider Name (Legal Business Name): LARRY WILLIAM KOTEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 FRANCE AVE S SUITE 100
EDINA MN
55435-5847
US

IV. Provider business mailing address

7700 FRANCE AVE S SUITE 100
EDINA MN
55435-5847
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-7000
  • Fax: 952-920-3333
Mailing address:
  • Phone: 952-922-7000
  • Fax: 952-920-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number22030
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: