Healthcare Provider Details

I. General information

NPI: 1043423056
Provider Name (Legal Business Name): DALLAS COTTAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VERMONT AVE SUITE 403 DOCTORS TOWER
LOS ANGELES CA
90027-6005
US

IV. Provider business mailing address

1300 N VERMONT AVE SUITE 403 DOCTORS TOWER
LOS ANGELES CA
90027-6005
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-1300
  • Fax: 323-644-0997
Mailing address:
  • Phone: 323-644-1300
  • Fax: 323-644-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG27339
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberG27339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: