Provider Demographics
NPI:1225145048
Name:BOTROUS, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BOTROUS
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:WJB DORN VA MEDICAL CENTER
Mailing Address - Street 2:6439 GARNERS FERRY ROAD
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:
Practice Address - Street 1:WJB DORN VA MEDICAL CENTER
Practice Address - Street 2:6439 GARNERS FERRY ROAD
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21332207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology