Provider Demographics
NPI:1295034924
Name:WILLIAM F. COTHERN,D.O.,P.A.
Entity Type:Organization
Organization Name:WILLIAM F. COTHERN,D.O.,P.A.
Other - Org Name:DERMATOLOGY AND LASER CENTER OF FT. WORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:COTHERN
Authorized Official - Suffix:
Authorized Official - Credentials:DO,PA
Authorized Official - Phone:817-377-1243
Mailing Address - Street 1:4201 CAMP BOWIE BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3928
Mailing Address - Country:US
Mailing Address - Phone:817-377-1243
Mailing Address - Fax:817-763-0631
Practice Address - Street 1:4201 CAMP BOWIE BLVD
Practice Address - Street 2:STE. A
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3928
Practice Address - Country:US
Practice Address - Phone:817-377-1243
Practice Address - Fax:817-763-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9330207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J14UOtherMEDICARE PTAN
TX123065802Medicaid