Provider Demographics
NPI:1801859640
Name:COTTER, JASON WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:WILLIAM
Last Name:COTTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 BAYLOR DR
Mailing Address - Street 2:SUITE 290
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-8965
Mailing Address - Country:US
Mailing Address - Phone:843-705-8919
Mailing Address - Fax:843-705-7024
Practice Address - Street 1:75 BAYLOR DR
Practice Address - Street 2:SUITE 290
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8965
Practice Address - Country:US
Practice Address - Phone:843-705-8919
Practice Address - Fax:843-705-7024
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200300326208600000X
SCTL31669208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134Y8Medicaid
SC316697Medicaid
SCP00758987Medicare PIN
SC316697Medicaid
NC89134Y8Medicaid
SCAA36939233Medicare PIN
NCH86108Medicare UPIN