Basic Information
| Provider Information | |||||||||
| NPI: | 1154485621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTLAREWSKY | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 IRVING ST NW | ||||||||
| Address2: | STE 2A-38E | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028774677 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 IRVING ST NW | ||||||||
| Address2: | STE 2A-38E | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200102975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028774677 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD036355 | DC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 024905300 | 05 | DC | MEDICAID |