Healthcare Provider Details

I. General information

NPI: 1700946340
Provider Name (Legal Business Name): PETRUSIA G KOTLAR DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 5TH AVE STE 2111
NEW YORK NY
10017
US

IV. Provider business mailing address

501 5TH AVE SUITE 2111
NEW YORK NY
10017
US

V. Phone/Fax

Practice location:
  • Phone: 212-599-2554
  • Fax: 212-599-2554
Mailing address:
  • Phone: 212-599-2554
  • Fax: 212-599-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX0039241
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00282800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: