1093912149 NPI number — MR. CHRISTOPHER DOUGLAS KOTZ IDC

Table of content: MR. CHRISTOPHER DOUGLAS KOTZ IDC (NPI 1093912149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093912149 NPI number — MR. CHRISTOPHER DOUGLAS KOTZ IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOTZ
Provider First Name:
CHRISTOPHER
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093912149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13044 YERBA VALLEY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKESIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92040-1579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-881-8696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3325 SENN RD
Provider Second Line Business Practice Location Address:
BUILDING 55, ROOM 225
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92136-5029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-556-5454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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