Provider Demographics
NPI:1417177072
Name:BOTTA, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BOTTA
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 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6099
Mailing Address - Country:US
Mailing Address - Phone:203-739-7070
Mailing Address - Fax:203-739-8931
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7070
Practice Address - Fax:203-739-8931
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045288207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11696737OtherCAQH NUMBER
1417177072OtherNPI NUMBER
CT290000442Medicare PIN