Provider Demographics
NPI:1043423056
Name:COTTAM, DALLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:
Last Name:COTTAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N VERMONT AVE
Mailing Address - Street 2:SUITE 403 DOCTORS TOWER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-644-1300
Mailing Address - Fax:323-644-0997
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:SUITE 403 DOCTORS TOWER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-644-1300
Practice Address - Fax:323-644-0997
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27339207P00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G27339Medicaid
CAG27339Medicare ID - Type Unspecified
CAA43326Medicare UPIN