Healthcare Provider Details

I. General information

NPI: 1205363454
Provider Name (Legal Business Name): KOTLYAR MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 LEXINGTON AVE RM 800
NEW YORK NY
10017-6536
US

IV. Provider business mailing address

PO BOX 270
MASSAPEQUA PARK NY
11762-0270
US

V. Phone/Fax

Practice location:
  • Phone: 631-264-2030
  • Fax: 631-264-1418
Mailing address:
  • Phone: 631-264-2035
  • Fax: 631-264-1418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number263221
License Number StateNY

VIII. Authorized Official

Name: DR. VITALY KOTLYAR
Title or Position: OWNER
Credential: MD
Phone: 917-862-5558