Basic Information
| Provider Information | |||||||||
| NPI: | 1922112762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEONID KOTKIN, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386368 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 WASHINGTON ST | ||||||||
| Address2: | STE. 207 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177838875 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | KOTKIN | ||||||||
| AuthorizedOfficialFirstName: | LEONID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6177838875 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 200208861 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 9755161 | 05 | MA | MEDICAID |