Provider Demographics
NPI:1104355429
Name:KOTENKO, MARIE (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:KOTENKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5301 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1149
Mailing Address - Country:US
Mailing Address - Phone:561-548-3836
Mailing Address - Fax:
Practice Address - Street 1:5301 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1149
Practice Address - Country:US
Practice Address - Phone:561-548-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301112188207P00000X
FLME146375207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine