Healthcare Provider Details

I. General information

NPI: 1679542799
Provider Name (Legal Business Name): MARK J KOTAPKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD YORK ROAD KLEIN BLDG, STE 501
PHILADELPHIA PA
19141
US

IV. Provider business mailing address

101 E OLNEY AVE 400
PHILADELPHIA PA
19120-2421
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-6127
  • Fax: 215-457-7602
Mailing address:
  • Phone: 215-456-7000
  • Fax: 215-254-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberPA MD040762E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: