Provider Demographics
NPI:1033195417
Name:BOTHWELL, NICI EDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:NICI
Middle Name:EDDY
Last Name:BOTHWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILTSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2855
Mailing Address - Country:US
Mailing Address - Phone:808-292-2752
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS6364207YS0012X, 207YS0012X
WAMD60209581207Y00000X
HI12650207YS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology