Healthcare Provider Details

I. General information

NPI: 1164551594
Provider Name (Legal Business Name): GREGORY CONRAD KOTHEIMER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LOWER NAVY HILL
GARAPAN SAIPAN
96950
UM

IV. Provider business mailing address

3728 SOUTHPARK DR
TYLER TX
75703-1707
US

V. Phone/Fax

Practice location:
  • Phone: 670-285-2626
  • Fax: 670-236-8600
Mailing address:
  • Phone: 903-595-7349
  • Fax: 903-593-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0410
License Number StateMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: