Healthcare Provider Details

I. General information

NPI: 1356423768
Provider Name (Legal Business Name): JOSEPH GUY KOTORA JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL CAMP LEJEUNE
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

824 COMMONS DR N
JACKSONVILLE NC
28546-8146
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4840
  • Fax:
Mailing address:
  • Phone: 732-266-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2014-01514
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number2014-01514
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: