Basic Information
Provider Information | |||||||||
NPI: | 1942264130 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COTTON | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | BERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 908 | ||||||||
Address2: |   | ||||||||
City: | MCALESTER | ||||||||
State: | OK | ||||||||
PostalCode: | 745020908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184260240 | ||||||||
FaxNumber: | 9184234051 | ||||||||
Practice Location | |||||||||
Address1: | 1401 E VAN BUREN AVE | ||||||||
Address2: |   | ||||||||
City: | MCALESTER | ||||||||
State: | OK | ||||||||
PostalCode: | 745014245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184260240 | ||||||||
FaxNumber: | 9184234051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 04/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9350 | OK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0166707 | 01 | OK | UMWA | OTHER | 730710406019 | 01 | OK | BC/BS | OTHER | 731310891028 | 01 | OK | TRICARE SOUTH | OTHER | 1324230001 | 01 | OK | PALMETTO DME | OTHER | 731310891006 | 01 | OK | UNICARE | OTHER | D34546 | 01 | OK | STERLING OPTION 1 | OTHER | 74502A009 | 01 | OK | CHAMPUS (WPS) | OTHER |