Provider Demographics
NPI:1235199373
Name:BOTELHO, RONALD J (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:BOTELHO
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:PO BOX 14578
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-6578
Mailing Address - Country:US
Mailing Address - Phone:707-569-3230
Mailing Address - Fax:707-523-0119
Practice Address - Street 1:1221 FARMERS LN
Practice Address - Street 2:SUITE 500
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6712
Practice Address - Country:US
Practice Address - Phone:707-569-3230
Practice Address - Fax:707-523-0119
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10484207L00000X
CAG53308207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100501809Medicaid
NVV37871Medicare PIN
A52492Medicare UPIN