Provider Demographics
NPI:1578506986
Name:DE COTIIS, JOHN R (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:DE COTIIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-0210
Mailing Address - Country:US
Mailing Address - Phone:856-218-1330
Mailing Address - Fax:856-218-1332
Practice Address - Street 1:30 W HOLLY AVE
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-1405
Practice Address - Country:US
Practice Address - Phone:856-218-1330
Practice Address - Fax:856-218-1332
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00636000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ001811403OtherIBX PPO
NJ7466688OtherAETNA
NJ2646509000OtherAMERIHEALTH
NJ2646509000OtherIBX HMO
NJ7466688OtherAETNA