Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | G27339 | CA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | G27339 | CA |
NPI | 1043423056 |
---|---|
Provider Name | Dr. Dallas Cottam |
First Address | Los Angeles, CA 90027-6005 |
Second Address | Los Angeles, CA 90027-6005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 02/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G27339 | (05) | CA |
A43326 | (02) | CA |