Provider Demographics
NPI:1306197595
Name:MARK W. COTTON, D.O.
Entity type:Organization
Organization Name:MARK W. COTTON, D.O.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-536-6600
Mailing Address - Street 1:5610 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9635
Mailing Address - Country:US
Mailing Address - Phone:580-536-6600
Mailing Address - Fax:580-536-2427
Practice Address - Street 1:5610 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9635
Practice Address - Country:US
Practice Address - Phone:580-536-6600
Practice Address - Fax:580-536-2427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3005208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101580BMedicaid