Healthcare Provider Details

I. General information

NPI: 1407936578
Provider Name (Legal Business Name): LAURA COTTAM DEWITT O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA COTTAM VAN DER WAAG O.D.

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 190 AND NAVAJO ROUTE 35/RED MESA
TEEC NOS POS AZ
86514
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5020
  • Fax:
Mailing address:
  • Phone: 505-368-6001
  • Fax: 928-656-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000350
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: