Provider Demographics
NPI:1275543431
Name:COTTLE, CHARLES E II (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:COTTLE
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-644-5356
Mailing Address - Fax:405-636-7946
Practice Address - Street 1:4219 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3410
Practice Address - Country:US
Practice Address - Phone:405-644-5356
Practice Address - Fax:405-636-7946
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34905208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176783000OtherOWCP
TX250006941OtherMEDICARE R.R.
TX2221992OtherBLUE LINK
TX4103577OtherAETNA
TX1311425-05Medicaid
TX250006941OtherMEDICARE R.R.
TX176783000OtherOWCP