1720079163 NPI number — JAMES M COTTOM DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720079163 NPI number — JAMES M COTTOM DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COTTOM
Provider First Name:
JAMES
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720079163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15815 SHADDOCK DR STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER GARDEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34787-5773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-400-1140
Provider Business Mailing Address Fax Number:
813-701-9132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5741 BEE RIDGE RD STE 490
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34233-5062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-924-8777
Provider Business Practice Location Address Fax Number:
941-924-5888
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  36-003432 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 5901002108 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: P03305 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: PO3305 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 340658000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4856313290 . This is a "BCBSM PIN#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7934680 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17192 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2643456 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4752578 TYPE 13 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4752569 TYPE 13 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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