Healthcare Provider Details

I. General information

NPI: 1699262972
Provider Name (Legal Business Name): JUSTIN KOTLIAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2018
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAPITAL WAY
PENNINGTON NJ
08534-2520
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 800-637-2374
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA12259500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: