Provider Demographics
NPI:1982221149
Name:COTTON, KARL CORNELIOUS
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:CORNELIOUS
Last Name:COTTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-4832
Mailing Address - Country:US
Mailing Address - Phone:269-277-9142
Mailing Address - Fax:
Practice Address - Street 1:946 MONROE ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4832
Practice Address - Country:US
Practice Address - Phone:269-277-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9210905Medicaid