Provider Demographics
NPI:1629174941
Name:COTTAM, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:COTTAM
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 1:14310 N DALE MABRY HWY STE 180
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2059
Mailing Address - Country:US
Mailing Address - Phone:813-962-4210
Mailing Address - Fax:813-962-0566
Practice Address - Street 1:14310 N DALE MABRY HWY STE 180
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2059
Practice Address - Country:US
Practice Address - Phone:813-962-4210
Practice Address - Fax:813-962-0566
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072051207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000831900Medicaid
FL46357AMedicare PIN
FL46357ZMedicare PIN