Provider Demographics
NPI:1275530917
Name:BOTNICK, LESLIE E (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:E
Last Name:BOTNICK
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 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5522 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3437
Practice Address - Country:US
Practice Address - Phone:818-997-1522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG376452085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG37645DOtherHC MEDICARE
CO654518OtherSWEDISH MEDICAID
CA00G376450Medicaid
CO449778OtherSWEDISH MEDICARE
CAWG37645GOtherSJHC MEDICARE
CAWG37645AOtherPSJ MEDICARE
CAWG37645KOtherSJO MEDICARE
CAWG37645AOtherPSJ MEDICARE
A91916Medicare UPIN
CA00G6376451Medicare PIN
CAWG37645GOtherSJHC MEDICARE