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General NPI Number Information
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NPI Number | 1235126053
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Entity Type | Individual
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Provider Name | THOMAS KOTHEIMER PA
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Gender | Male
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Dates
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Enumeration Date | 10/06/2005
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Last Update Date | 05/24/2012
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Provider Practice Location Address
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Address Line | 2161 KINGSLEY AVE STE 200
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City | ORANGE PARK
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State | FL
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Zip | 32073-5113
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Country | US
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Telephone | 904-727-3139
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Fax | 904-276-7434
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Provider Business Mailing Address
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Address Line | 9143 PHILIPS HWY STE 560
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City | JACKSONVILLE
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State | FL
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Zip | 32256-1348
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Country | US
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Telephone | 904-363-2113
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Fax | 904-363-7453
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA 2559
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License Number State | FL
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