Provider Demographics
NPI:1417017302
Name:COTTRELL, KEVIN C (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 DRY CREEK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7732
Mailing Address - Country:US
Mailing Address - Phone:303-776-1620
Mailing Address - Fax:720-204-2028
Practice Address - Street 1:1325 DRY CREEK DR STE 104
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503
Practice Address - Country:US
Practice Address - Phone:303-776-1620
Practice Address - Fax:720-204-2028
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU97519Medicare UPIN
CO4482420001Medicare NSC
CO803661Medicare ID - Type Unspecified