Provider Demographics
NPI:1447343116
Name:COTTLE, JOHN ERNEST JR (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ERNEST
Last Name:COTTLE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 RIVER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-961-4631
Mailing Address - Fax:707-964-1192
Practice Address - Street 1:721 RIVER DR
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-4631
Practice Address - Fax:707-964-1192
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34047207Q00000X
CA20A10161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01340470Medicaid
D4318Medicare ID - Type Unspecified
E26042Medicare UPIN