Basic Information
| Provider Information | |||||||||
| NPI: | 1558340174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTTRELL | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3211 DUDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261041813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044223904 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1824 MURDOCH AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044244695 | ||||||||
| FaxNumber: | 3044223924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 19769 | WV | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 35087051 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 200101192 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1841933000 | 05 | WV | MEDICAID | 2411223 | 05 | OH | MEDICAID |