=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124110572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM COTTLES, JR., M.D.,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3756 SANTA ROSALIA DR. SUITE 503
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90008-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-295-6521
-----------------------------------------------------
Fax | 323-295-0228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3756 SANTA ROSALIA DR. SUITE 503
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90008-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-295-6521
-----------------------------------------------------
Fax | 323-295-0228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM (NONE) COTTLES JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-295-6521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | C23419
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------