Provider Demographics
NPI:1124227772
Name:BOTROS, ISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:ISSA
Middle Name:M
Last Name:BOTROS
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 1:1499 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3255
Mailing Address - Country:US
Mailing Address - Phone:310-241-2590
Mailing Address - Fax:
Practice Address - Street 1:1499 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3255
Practice Address - Country:US
Practice Address - Phone:310-241-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090843207QA0505X
CAA106987207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine