Provider Demographics
NPI:1134451487
Name:KOTOWSKI, JACEK (MD)
Entity type:Individual
Prefix:DR
First Name:JACEK
Middle Name:
Last Name:KOTOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4907
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4907
Mailing Address - Country:US
Mailing Address - Phone:406-541-3937
Mailing Address - Fax:406-541-3811
Practice Address - Street 1:700 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6772
Practice Address - Country:US
Practice Address - Phone:406-541-3937
Practice Address - Fax:406-541-3811
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT49655207WX0107X, 207W00000X
PA199989207W00000X
NMRS2013-0655207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1134451487Medicaid