Provider Demographics
NPI:1063550598
Name:COTTRELL, MARK A (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MANTOLOKING RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-5814
Mailing Address - Country:US
Mailing Address - Phone:732-477-1256
Mailing Address - Fax:
Practice Address - Street 1:875 POOLE AVE
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-2041
Practice Address - Country:US
Practice Address - Phone:732-264-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00608200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ607658Medicare ID - Type Unspecified