Provider Demographics
NPI:1568771384
Name:COTTAGE LAKE PODIATRY
Entity Type:Organization
Organization Name:COTTAGE LAKE PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:434-432-8417
Mailing Address - Street 1:148 FRANCIS RD
Mailing Address - Street 2:
Mailing Address - City:JAVA
Mailing Address - State:VA
Mailing Address - Zip Code:24565-2000
Mailing Address - Country:US
Mailing Address - Phone:434-432-8417
Mailing Address - Fax:
Practice Address - Street 1:148 FRANCIS RD
Practice Address - Street 2:
Practice Address - City:JAVA
Practice Address - State:VA
Practice Address - Zip Code:24565-2000
Practice Address - Country:US
Practice Address - Phone:434-432-8417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300987213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty