Provider Demographics
NPI:1710061213
Name:COTTRELL, KENNETH W (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:COTTRELL
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 1:341 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1051
Mailing Address - Country:US
Mailing Address - Phone:606-789-4675
Mailing Address - Fax:606-789-3262
Practice Address - Street 1:341 COURT ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1051
Practice Address - Country:US
Practice Address - Phone:606-789-4675
Practice Address - Fax:606-789-3262
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY724DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77007243Medicaid
KY9365203Medicare ID - Type Unspecified
KY77007243Medicaid