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General NPI Number Information
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NPI Number | 1922090646
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Entity Type | Individual
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Provider Name | JACK PETER KOTLARZ MD
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Gender | Male
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Dates
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Enumeration Date | 08/18/2005
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 1253 N ALPINE RD
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City | ROCKFORD
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State | IL
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Zip | 61107-2201
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Country | US
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Telephone | 779-696-9201
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Fax | 815-397-9667
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Provider Business Mailing Address
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Address Line | 6100 NORTH DAVIS HWY
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City | PENSACOLA
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State | FL
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Zip | 32504-6950
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Country | US
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Telephone | 850-471-2377
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Fax | 850-471-9975
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | ME62757
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | ME62757
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 2024013411
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | 036170362
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License Number State | IL
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