Basic Information
| Provider Information | |||||||||
| NPI: | 1760574776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COTTAM | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RHEAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 E 100 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017462885 | ||||||||
| FaxNumber: | 7023848446 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 E 100 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017462885 | ||||||||
| FaxNumber: | 8017462886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10997 | NV | N | Other Service Providers | Specialist | 208600000X | 6655906-1205 | UT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1760574776 | 05 | UT | MEDICAID | 100503622 | 05 | NV | MEDICAID | 10997 | 01 | NV | MD# | OTHER |