Provider Demographics
NPI:1326579475
Name:BOTTYAN, THOMAS
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:BOTTYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 QUARRY RD UPPR CA94304
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1419
Mailing Address - Country:US
Mailing Address - Phone:650-723-8335
Mailing Address - Fax:
Practice Address - Street 1:401 QUARRY RD UPPR CA94304
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1419
Practice Address - Country:US
Practice Address - Phone:650-723-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1600692084A0401X, 2084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program