Healthcare Provider Details

I. General information

NPI: 1215913264
Provider Name (Legal Business Name): STEPHEN W COTLAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 N 7TH ST
GRAND JUNCTION CO
81501-1628
US

IV. Provider business mailing address

PO BOX 62
GRAND JUNCTION CO
81502-0062
US

V. Phone/Fax

Practice location:
  • Phone: 970-298-6307
  • Fax: 970-298-7037
Mailing address:
  • Phone: 970-298-6307
  • Fax: 970-298-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number43223
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number43223
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: