Healthcare Provider Details

I. General information

NPI: 1013023357
Provider Name (Legal Business Name): SANDEEP V KOTAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36100 EUCLID AVE STE 240
WILLOUGHBY OH
44094-4427
US

IV. Provider business mailing address

7590 AUBURN ROAD, SUITE 014 ATTN: MED STAFF
CONCORD TWP OH
44077-9176
US

V. Phone/Fax

Practice location:
  • Phone: 440-953-6294
  • Fax: 440-918-4687
Mailing address:
  • Phone: 440-354-1899
  • Fax: 440-354-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-070626
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: