Provider Demographics
NPI:1407936578
Name:DEWITT, LAURA COTTAM (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:COTTAM
Last Name:DEWITT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:COTTAM
Other - Last Name:VAN DER WAAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:928-656-5021
Practice Address - Street 1:US HWY 190 AND NAVAJO ROUTE 35/RED MESA
Practice Address - Street 2:
Practice Address - City:TEEC NOS POS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist