Healthcare Provider Details

I. General information

NPI: 1023397668
Provider Name (Legal Business Name): BIANA KOTLYAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2011
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 N LAKE DR 1ST FLOOR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

4425 N PORT WASHINGTON RD
GLENDALE WI
53212-1082
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-1620
  • Fax: 414-291-5969
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125-060700
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number64276
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: