Individual
ERIC RUSSELL KOTAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
707 S UNIVERSITY AVE, BEAVER DAM, WI 53916-3027
(920) 887-6606
Mailing address
100 MCINTOSH DR, BEAVER DAM, WI 53916-9255
(815) 450-8972
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
4301097060
MI
390200000X
Student in an Organized Health Care Education/Training Program
4301097060
MI
Other
Enumeration date
06/23/2010
Last updated
04/21/2017
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