Provider Demographics
NPI:1497178651
Name:COTTON-SMITH, DELORIS
Entity Type:Individual
Prefix:
First Name:DELORIS
Middle Name:
Last Name:COTTON-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 KNOLLCROFT RD
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1938
Mailing Address - Country:US
Mailing Address - Phone:937-837-3561
Mailing Address - Fax:
Practice Address - Street 1:4625 KNOLLCROFT RD
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-1938
Practice Address - Country:US
Practice Address - Phone:937-837-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171W00000X-CONTRACTO171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105865396399Medicaid