Healthcare Provider Details

I. General information

NPI: 1558586255
Provider Name (Legal Business Name): SUSAN C. COTTONGIM RD,LDN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 800-749-5191
  • Fax: 410-912-4972
Mailing address:
  • Phone: 410-543-7531
  • Fax: 410-912-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDO1209
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: