Provider Demographics
NPI:1104888361
Name:KOTAL, CHARLES VLADIMIR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:VLADIMIR
Last Name:KOTAL
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:360-293-4343
Mailing Address - Fax:360-588-1587
Practice Address - Street 1:912 32ND ST.
Practice Address - Street 2:STE A
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221
Practice Address - Country:US
Practice Address - Phone:360-416-5750
Practice Address - Fax:360-416-5758
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035345207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8229627Medicaid
GAB33047OtherGROUP
WA8229627Medicaid
G8872770Medicare PIN
GAB33047OtherGROUP
G74947Medicare UPIN