Provider Demographics
NPI:1336194836
Name:COTTRELL, RODERICA E (MD)
Entity Type:Individual
Prefix:
First Name:RODERICA
Middle Name:E
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 IRIS DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-0907
Mailing Address - Country:US
Mailing Address - Phone:770-787-4042
Mailing Address - Fax:770-787-4001
Practice Address - Street 1:3211 IRIS DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-0907
Practice Address - Country:US
Practice Address - Phone:770-787-4042
Practice Address - Fax:770-787-4001
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054986208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA649893594AMedicaid
GA649893594BMedicaid
GA649893594AMedicaid
GAI52979Medicare UPIN