Provider Demographics
NPI:1245420926
Name:KEVIN COTTER ODPA
Entity Type:Organization
Organization Name:KEVIN COTTER ODPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-455-2197
Mailing Address - Street 1:618 WINTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-6542
Mailing Address - Country:US
Mailing Address - Phone:208-466-1395
Mailing Address - Fax:208-466-1395
Practice Address - Street 1:5108 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-8002
Practice Address - Country:US
Practice Address - Phone:208-455-2197
Practice Address - Fax:208-455-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1592829OtherMEDICARE PROVIDER NUMBER
IDU59403Medicare UPIN