Provider Demographics
NPI:1437342060
Name:BOTTORFF, JOHN JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:BOTTORFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BOTTORFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:407 ULUNIU ST STE 411
Mailing Address - Street 2:#411
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2544
Mailing Address - Country:US
Mailing Address - Phone:808-263-7203
Mailing Address - Fax:
Practice Address - Street 1:407 ULUNIU ST STE 411
Practice Address - Street 2:#411
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2544
Practice Address - Country:US
Practice Address - Phone:808-263-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6686207P00000X
HIMD-16745207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine