Provider Demographics
NPI:1033192844
Name:BOTNICK, MARC I (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:I
Last Name:BOTNICK
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18133 VENTURA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3641
Practice Address - Country:US
Practice Address - Phone:424-314-7695
Practice Address - Fax:424-314-7699
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72882174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A728820Medicaid
CAWA72882GMedicare PIN
CAWA72882DMedicare PIN
CAWA72882AMedicare PIN
CO442018Medicare PIN
CA00A728820Medicaid
CAWA72882NMedicare PIN
CAWA72882LMedicare PIN
CAWA72882MMedicare PIN
CAWA72882BMedicare PIN
CAH22979Medicare UPIN
CAWA72882CMedicare PIN
CAWA72882KMedicare PIN