Provider Demographics
NPI:1902398407
Name:KOTULSKI, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KOTULSKI
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 1:84042 310TH ST
Mailing Address - Street 2:
Mailing Address - City:MADELIA
Mailing Address - State:MN
Mailing Address - Zip Code:56062-5417
Mailing Address - Country:US
Mailing Address - Phone:507-380-4069
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60863184207Q00000X
WI75407-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine