Healthcare Provider Details

I. General information

NPI: 1760859862
Provider Name (Legal Business Name): BRETT KOTLUS M.D. PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E 71ST ST 1A
NEW YORK NY
10021-4258
US

IV. Provider business mailing address

135 E 71ST ST 1A
NEW YORK NY
10021-4258
US

V. Phone/Fax

Practice location:
  • Phone: 212-882-1011
  • Fax:
Mailing address:
  • Phone: 212-882-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number231319
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number231319
License Number StateNY

VIII. Authorized Official

Name: BRETT KOTLUS
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 212-882-1011