Provider Demographics
NPI:1295755577
Name:COTTER, MICHAEL PATRICK (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
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 1:1325 PENNSYLVANIA AVE STE 740
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2144
Mailing Address - Country:US
Mailing Address - Phone:817-250-2890
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 740
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-250-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9138208000000X, 208M00000X
KS04-31771208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1295755577Medicaid
KSKA2129004OtherMEDICARE PTAN
KS200379560AMedicaid