Basic Information
Provider Information | |||||||||
NPI: | 1134451487 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOTOWSKI | ||||||||
FirstName: | JACEK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4907 | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598064907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4065413937 | ||||||||
FaxNumber: | 4065413811 | ||||||||
Practice Location | |||||||||
Address1: | 700 W KENT AVE | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598016772 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4065413937 | ||||||||
FaxNumber: | 4065413811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2010 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 49655 | MT | N |   |   |   |   | 207W00000X | 49655 | MT | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 199989 | PA | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | RS2013-0655 | NM | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 1134451487 | 05 | MT |   | MEDICAID |