Provider Demographics
NPI:1649255852
Name:KOTLARCZYK, JUSTIN MARK (PT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MARK
Last Name:KOTLARCZYK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 3RD AVE W
Mailing Address - Street 2:STE 110
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8641
Mailing Address - Country:US
Mailing Address - Phone:941-708-9555
Mailing Address - Fax:941-708-5200
Practice Address - Street 1:2722 MANATEE AVE W
Practice Address - Street 2:SUITE 2
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-4945
Practice Address - Country:US
Practice Address - Phone:941-744-9046
Practice Address - Fax:941-744-9046
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY060COtherBCBS
FLY060COtherBCBS
FLY060CZMedicare ID - Type Unspecified