Individual
JACK PETER KOTLARZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1253 N ALPINE RD, ROCKFORD, IL 61107-2201
(779) 696-9201
(815) 397-9667
Mailing address
6100 NORTH DAVIS HWY, PENSACOLA, FL 32504-6950
(850) 471-2377
(850) 471-9975
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
ME62757
FL
207Y00000X
Otolaryngology Physician
2024013411
MO
207Y00000X
Otolaryngology Physician
ME62757
FL
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
Primary
036170362
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
009900475
MEDICAID ALA
AL
01
—
040016528
UHC MCR RR
FL
05
—
253548300
—
FL
01
—
42544
BCBS OF FLORIDA
FL
01
—
4314144
AETNA
FL
01
—
590 51780
BCBS OF ALA
AL
01
—
7618346003
CIGNA PPO
FL
Enumeration date
08/18/2005
Last updated
12/10/2024
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