Provider Demographics
NPI:1356309512
Name:COTTAM, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
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 1:560 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3746
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:801-224-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6501499-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107056147101OtherIHC
UT870284448008Medicaid
UT35014991200001OtherBX
UT870284448DCMOtherEMIA
UT870284448DCMOtherDMBA
UT000061109Medicare PIN
UT870284448DCMOtherEMIA