Provider Demographics
NPI:1417139577
Name:B BOTTENBERG D O PRFSNL CORP
Entity Type:Organization
Organization Name:B BOTTENBERG D O PRFSNL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:B
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BOTTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:775-883-3953
Mailing Address - Street 1:550 W WASHINGTON ST
Mailing Address - Street 2:STE 1
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3829
Mailing Address - Country:US
Mailing Address - Phone:775-883-3953
Mailing Address - Fax:775-885-2785
Practice Address - Street 1:550 W WASHINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3829
Practice Address - Country:US
Practice Address - Phone:775-883-3953
Practice Address - Fax:775-885-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV39144Medicare PIN