Provider Demographics
NPI:1053304972
Name:BOTTNER, MELVIN L (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:L
Last Name:BOTTNER
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 1:16100 N 71ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2225
Mailing Address - Country:US
Mailing Address - Phone:480-656-0016
Mailing Address - Fax:480-634-1723
Practice Address - Street 1:16100 N 71ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2209
Practice Address - Country:US
Practice Address - Phone:480-656-0016
Practice Address - Fax:480-634-1723
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2012-02-23
Deactivation Date:2005-11-17
Deactivation Code:
Reactivation Date:2005-12-01
Provider Licenses
StateLicense IDTaxonomies
AZ11143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ257073-02Medicaid
AZ257073-02Medicaid
AZZ63382Medicare PIN