Provider Demographics
NPI:1861571960
Name:KOTOSKE, THOMAS G (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:KOTOSKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19636 N 27TH AVE
Mailing Address - Street 2:#101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027
Mailing Address - Country:US
Mailing Address - Phone:623-516-2639
Mailing Address - Fax:623-580-0019
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:#101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027
Practice Address - Country:US
Practice Address - Phone:623-516-2639
Practice Address - Fax:623-580-0019
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3065207YX0905X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329145Medicaid
AZ329145Medicaid
F89749Medicare UPIN