Healthcare Provider Details

I. General information

NPI: 1346862679
Provider Name (Legal Business Name): THOMAS KOTNIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 10/15/2023
Certification Date: 10/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18511 HIGHLANDER MEDICS ST
FORT BLISS TX
79906-5327
US

IV. Provider business mailing address

18511 HIGHLANDER MEDICS ST
FORT BLISS TX
79906-5327
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-2273
  • Fax:
Mailing address:
  • Phone: 915-742-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT9724
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: