Provider Demographics
NPI:1003853177
Name:BOTSTEIN, GARY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:BOTSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5930
Mailing Address - Country:US
Mailing Address - Phone:404-299-0187
Mailing Address - Fax:404-292-2766
Practice Address - Street 1:2712 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5930
Practice Address - Country:US
Practice Address - Phone:404-299-0187
Practice Address - Fax:404-292-2766
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022515207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00252315BMedicaid
GA00252315BMedicaid