MEDICARE: DR. WAYNE ROBERT KOTTER DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0511	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	480157299	OTHER	UT	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1154326429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE ROBERT KOTTER DPM

Provider Business Mailing Address
First Line	:	5320 S 1950 W
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-2402
Country	:	US
Telephone Number	:	801-773-6565
Fax Number	:	801-774-6967

Provider Business Practice Location Address
First Line	:	5320 S 1950 W
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-2402
Country	:	US
Telephone Number	:	801-773-6565
Fax Number	:	801-774-6967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	10/06/2008

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