MEDICARE: MR. ERNEST MARVIN KOTLIER M.D.

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	207Q00000X	Family Medicine Physician	CFE28391	CA

General Provider Information

NPI Number	:	1811269566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERNEST MARVIN KOTLIER M.D.

Provider Business Mailing Address
First Line	:	1555 SCENIC AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94708-1813
Country	:	US
Telephone Number	:	510-368-1221
Fax Number	:	510-548-1727

Provider Business Practice Location Address
First Line	:	1555 SCENIC AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94708-1813
Country	:	US
Telephone Number	:	510-368-1221
Fax Number	:	510-548-1727

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

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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