Basic Information
| Provider Information | |||||||||
| NPI: | 1710924139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTTONGIM | ||||||||
| FirstName: | TONI | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637676 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134810900 | ||||||||
| FaxNumber: | 5134810904 | ||||||||
| Practice Location | |||||||||
| Address1: | 6350 GLENWAY AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452116378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134810900 | ||||||||
| FaxNumber: | 5134810904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35072447 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2055369 | 05 | OH | MEDICAID |