Healthcare Provider Details

I. General information

NPI: 1619967957
Provider Name (Legal Business Name): TRACY ANN KOTNIK M.D., F.A.A.F.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2859 AARONWOOD AVE NE UNIT 3
MASSILLON OH
44646-2371
US

IV. Provider business mailing address

3218 WOODRIDGE AVE NW
CANTON OH
44718-3448
US

V. Phone/Fax

Practice location:
  • Phone: 330-832-2280
  • Fax: 330-832-4732
Mailing address:
  • Phone: 330-456-5472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35062187K
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: