Provider Demographics
NPI:1710961248
Name:COTTEL, WILLIS I (MD)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:I
Last Name:COTTEL
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 1:2215 CEDAR SPRINGS RD
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1859
Mailing Address - Country:US
Mailing Address - Phone:214-468-0403
Mailing Address - Fax:214-468-8375
Practice Address - Street 1:2215 CEDAR SPRINGS RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-1859
Practice Address - Country:US
Practice Address - Phone:214-468-0403
Practice Address - Fax:214-468-8375
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE6759207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00AM71Medicare ID - Type Unspecified
TXB21987Medicare UPIN