Provider Demographics
NPI:1346341351
Name:BOTKIN, GREGORY T (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:BOTKIN
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 1:6640 KANIKSU ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-3141
Mailing Address - Fax:208-267-0660
Practice Address - Street 1:6640 KANIKSU ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-7205OtherSTATE LICENSE
ID1346341351Medicaid
IDCS-7048OtherIDAHO CONTROLLED SUBSTANC
IDCS-7048OtherIDAHO CONTROLLED SUBSTANC
ID1346341351Medicaid
ID1137519Medicare PIN