Provider Demographics
NPI:1740222512
Name:COTTRELL, CARL C (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:C
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:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-0002
Mailing Address - Country:US
Mailing Address - Phone:307-347-6141
Mailing Address - Fax:307-347-6142
Practice Address - Street 1:820 COBURN AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3317
Practice Address - Country:US
Practice Address - Phone:307-347-6141
Practice Address - Fax:307-347-6142
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY255T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200460Medicaid
WY307683OtherBLUECROSS BLUE SHIELD
WY1134451-00Medicaid
WY307683Medicaid
WY307683Medicare ID - Type Unspecified
SD9200460Medicaid
WY307683OtherBLUECROSS BLUE SHIELD
WY307683Medicaid