Healthcare Provider Details

I. General information

NPI: 1790274298
Provider Name (Legal Business Name): KEITH WILLIAM KOTECKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 W WASHINGTON AVE STE 160
LAS VEGAS NV
89128-4356
US

IV. Provider business mailing address

620 SHADOW LN
LAS VEGAS NV
89106-4119
US

V. Phone/Fax

Practice location:
  • Phone: 702-878-0393
  • Fax:
Mailing address:
  • Phone: 702-388-8436
  • Fax: 702-388-8431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS022625
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: