Provider Demographics
NPI:1124121058
Name:COTTER, KEVIN CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:COTTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:COTTER ODPA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:618 WINTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-6542
Mailing Address - Country:US
Mailing Address - Phone:208-466-1395
Mailing Address - Fax:208-466-1395
Practice Address - Street 1:5108 E CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-8002
Practice Address - Country:US
Practice Address - Phone:208-455-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1592829Medicare ID - Type Unspecified