Provider Demographics
NPI:1083102305
Name:BOTROSS, MINA (DO)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BOTROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SADDLEBROOK SUBDIVISION RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9608
Mailing Address - Country:US
Mailing Address - Phone:201-993-8286
Mailing Address - Fax:
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:844-479-4545
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3651208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist