Provider Demographics
NPI:1891139143
Name:COTTER, MARK M (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:COTTER
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 1:2106 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3344
Mailing Address - Country:US
Mailing Address - Phone:318-412-5265
Mailing Address - Fax:318-435-3842
Practice Address - Street 1:2106 LOOP RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3344
Practice Address - Country:US
Practice Address - Phone:318-412-5265
Practice Address - Fax:318-435-3842
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1962988Medicaid
LA5U045OtherMEDICARE PTAN