Provider Demographics
NPI:1770696189
Name:COTTER, MAXWELL TRYGVE (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:TRYGVE
Last Name:COTTER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 N ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2210
Mailing Address - Country:US
Mailing Address - Phone:818-843-2415
Mailing Address - Fax:818-566-4345
Practice Address - Street 1:2511 N ORCHARD DR
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-2210
Practice Address - Country:US
Practice Address - Phone:818-843-2415
Practice Address - Fax:818-566-4345
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2094237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0024280Medicaid
CAHA0024280Medicaid