Healthcare Provider Details

I. General information

NPI: 1740222512
Provider Name (Legal Business Name): CARL C COTTRELL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 COBURN AVE
WORLAND WY
82401-3317
US

IV. Provider business mailing address

PO BOX 2
WORLAND WY
82401-0002
US

V. Phone/Fax

Practice location:
  • Phone: 307-347-6141
  • Fax: 307-347-6142
Mailing address:
  • Phone: 307-347-6141
  • Fax: 307-347-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number255T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: