Provider Demographics
NPI:1235126053
Name:KOTHEIMER, THOMAS (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KOTHEIMER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9143 PHILIPS HWY
Mailing Address - Street 2:STE 560
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1348
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-7453
Practice Address - Street 1:2161 KINGSLEY AVE
Practice Address - Street 2:STE 200
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5113
Practice Address - Country:US
Practice Address - Phone:904-727-3139
Practice Address - Fax:904-276-7434
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291828500Medicaid
FLY03PUOtherBCBSFL
FLE3594WMedicare PIN
FL291828500Medicaid
FLP00762566Medicare PIN
FLE3594VMedicare PIN