Healthcare Provider Details

I. General information

NPI: 1568771384
Provider Name (Legal Business Name): COTTAGE LAKE PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 FRANCIS RD
JAVA VA
24565-2000
US

IV. Provider business mailing address

148 FRANCIS RD
JAVA VA
24565-2000
US

V. Phone/Fax

Practice location:
  • Phone: 434-432-8417
  • Fax:
Mailing address:
  • Phone: 434-432-8417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300987
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ROGER PATRICK TRAVIS
Title or Position: OWNER
Credential: DPM
Phone: 434-432-8417