Healthcare Provider Details

I. General information

NPI: 1679832075
Provider Name (Legal Business Name): JESSE N COTTRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DR STE 4500
HUNTINGTON WV
25701-3656
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR STE 4500
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1400
  • Fax: 304-691-1453
Mailing address:
  • Phone: 304-691-1400
  • Fax: 304-691-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number28842
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number24283
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberTP405
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: