Provider Demographics
NPI:1104018928
Name:KHULOOD Y. COTTA M.D.
Entity Type:Organization
Organization Name:KHULOOD Y. COTTA M.D.
Other - Org Name:ST JUDE HEALTH CARE MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-773-0591
Mailing Address - Street 1:4946 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4319
Mailing Address - Country:US
Mailing Address - Phone:323-773-0591
Mailing Address - Fax:
Practice Address - Street 1:4946 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-4319
Practice Address - Country:US
Practice Address - Phone:323-773-0591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40215207Q00000X
CAA36591208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068540Medicaid
CAGR0068540OtherMEDICAL
CAW13749OtherMEDICARE
CAGR0068540OtherMEDICAL