Provider Demographics
NPI:1619911047
Name:COTTERAL, RUSSELL NORMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:NORMAN
Last Name:COTTERAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 COLUSA AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1209
Mailing Address - Country:US
Mailing Address - Phone:510-527-1714
Mailing Address - Fax:510-527-1715
Practice Address - Street 1:940 SYLVA LN STE H
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5969
Practice Address - Country:US
Practice Address - Phone:209-532-4132
Practice Address - Fax:209-532-6749
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12452OtherMEDICAL EYE SERVICES
CAZZZ04659ZMedicare PIN
CAFY844AMedicare PIN
CA12452OtherMEDICAL EYE SERVICES