Provider Demographics
NPI:1427039833
Name:BOTTORFF, JOHN M JR (DC, CCST)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:BOTTORFF
Suffix:JR
Gender:M
Credentials:DC, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-3146
Mailing Address - Country:US
Mailing Address - Phone:765-362-8833
Mailing Address - Fax:765-362-8852
Practice Address - Street 1:1709 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3146
Practice Address - Country:US
Practice Address - Phone:765-362-8833
Practice Address - Fax:765-362-8852
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000752A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4351321OtherAETNA PROVIDER ID
IN000000089177OtherANTHEM PROVIDER ID
IN0086213OtherCIGNA PROVIDER ID
IN645959OtherACN PROVIDER ID
INT34902Medicare UPIN
IN511440Medicare ID - Type Unspecified