Provider Demographics
NPI:1306040910
Name:BOTTS, STANLEY HORTON JR (OD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:HORTON
Last Name:BOTTS
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WYANDOTTE AVE E
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2934
Mailing Address - Country:US
Mailing Address - Phone:276-523-2319
Mailing Address - Fax:276-523-2319
Practice Address - Street 1:780 COMMONWEALTH DR
Practice Address - Street 2:OPTOMETRIST SUITE
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-4051
Practice Address - Country:US
Practice Address - Phone:276-870-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist