Basic Information
| Provider Information | |||||||||
| NPI: | 1053509869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTES | ||||||||
| FirstName: | ENRIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441163437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 15644 MADISON AVE | ||||||||
| Address2: | SUITE 218 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441075622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162279839 | ||||||||
| FaxNumber: | 2162279867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 10/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | 35-061827 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0896900 | 05 | OH | MEDICAID |