Provider Demographics
NPI:1669519385
Name:COTTERELL, KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:COTTERELL
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 1:400 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2508
Mailing Address - Country:US
Mailing Address - Phone:631-608-5204
Mailing Address - Fax:631-608-4112
Practice Address - Street 1:400 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2508
Practice Address - Country:US
Practice Address - Phone:631-608-5204
Practice Address - Fax:631-608-4112
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1888612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC54687Medicare UPIN
NY02L401Medicare ID - Type Unspecified