Provider Demographics
NPI:1417947771
Name:COOTS, NORVELL VANDERVALL (MD)
Entity Type:Individual
Prefix:DR
First Name:NORVELL
Middle Name:VANDERVALL
Last Name:COOTS
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 1:6759 MORNING RIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5057
Mailing Address - Country:US
Mailing Address - Phone:703-550-1920
Mailing Address - Fax:
Practice Address - Street 1:401 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:FT MYER
Practice Address - State:VA
Practice Address - Zip Code:22211-1009
Practice Address - Country:US
Practice Address - Phone:703-696-3447
Practice Address - Fax:703-696-3450
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17398207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology