Healthcare Provider Details

I. General information

NPI: 1790731651
Provider Name (Legal Business Name): PETIO VLADIMIROV KOTOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

500 CAMPUS DR.
HANCOCK MI
49930-1569
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-0000
  • Fax:
Mailing address:
  • Phone: 906-048-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301087243
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number042-0015453
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: