Provider Demographics
NPI:1689722324
Name:COTTLE OPTOMETRY, PC
Entity Type:Organization
Organization Name:COTTLE OPTOMETRY, PC
Other - Org Name:SUMMIT LAKES EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:COTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:816-623-9990
Mailing Address - Street 1:3700 SW CHEDDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-4797
Mailing Address - Country:US
Mailing Address - Phone:816-623-9990
Mailing Address - Fax:816-623-9449
Practice Address - Street 1:3700 SW CHEDDINGTON DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-4797
Practice Address - Country:US
Practice Address - Phone:816-623-9990
Practice Address - Fax:816-623-9449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20151442152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V03092Medicare UPIN
MOW950000Medicare PIN