Basic Information
| Provider Information | |||||||||
| NPI: | 1609830249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COTTER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273207173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363423336 | ||||||||
| FaxNumber: | 3363423226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1411 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 7909228 | 01 | NC | MEDICAID GROUP # | OTHER | 890905F | 05 | NC | MEDICAID | DD8241 | 01 | NC | RAILROAD MCARE GROUP # | OTHER | P00253796 | 01 | NC | RAILROAD MCARE PROV # | OTHER | 7909232 | 01 | NC | MEDICAID GROUP N# | OTHER | 011W8 | 01 | NC | BCBS GROUP # | OTHER | 017NK | 01 | NC | BCBS GROUP # | OTHER | 0905F | 01 | NC | BCBS PROV # | OTHER | 09228 | 01 | NC | BCBS GROUP # | OTHER | 89011W8 | 01 | NC | MEDICAID GROUP # | OTHER | 246648I | 01 | NC | MEDICARE GROUP # | OTHER | 246648W | 01 | NC | MEDICARE GROUP # | OTHER | 8909406 | 01 | NC | MEDICAID GROUP # | OTHER |