Provider Demographics
NPI:1669431326
Name:COTNER MEDICAL CLINIC
Entity type:Organization
Organization Name:COTNER MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:COTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-754-9945
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-0336
Mailing Address - Country:US
Mailing Address - Phone:479-754-9945
Mailing Address - Fax:479-754-9947
Practice Address - Street 1:25 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4432
Practice Address - Country:US
Practice Address - Phone:479-754-9945
Practice Address - Fax:479-754-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C879OtherARK BLUECROSS
AR5C897Medicare ID - Type Unspecified