Provider Demographics
NPI:1396743472
Name:COTTLE, JOHN L (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:COTTLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SW CHEDDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-4797
Mailing Address - Country:US
Mailing Address - Phone:816-623-9990
Mailing Address - Fax:816-623-9990
Practice Address - Street 1:3700 SW CHEDDINGTON DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-4797
Practice Address - Country:US
Practice Address - Phone:816-623-9990
Practice Address - Fax:816-623-9449
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016908152W00000X
KS1680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1396743472Medicaid
V03092Medicare UPIN
MO1396743472Medicaid