Provider Demographics
NPI:1962493445
Name:COTHERN, WILLIAM FORREST (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FORREST
Last Name:COTHERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 CAMP BOWIE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3928
Mailing Address - Country:US
Mailing Address - Phone:817-377-1243
Mailing Address - Fax:817-763-0631
Practice Address - Street 1:4201 CAMP BOWIE BLVD
Practice Address - Street 2:STE A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3928
Practice Address - Country:US
Practice Address - Phone:817-377-1243
Practice Address - Fax:817-763-0631
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9330207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75159Medicare UPIN
TX00J14UMedicare ID - Type Unspecified
D75159Medicare UPIN
TX00J14UMedicare ID - Type Unspecified