Provider Demographics
NPI:1093878654
Name:BOTVINNIK, VICTORIA MARATOVNA (DPT)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:MARATOVNA
Last Name:BOTVINNIK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 47TH ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5223
Mailing Address - Country:US
Mailing Address - Phone:612-245-6328
Mailing Address - Fax:
Practice Address - Street 1:185 MONTAGUE ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3608
Practice Address - Country:US
Practice Address - Phone:718-243-9900
Practice Address - Fax:718-243-1620
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028430-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ064EQA561Medicare PIN
NYQ064EQD252Medicare PIN