Provider Demographics
NPI:1467880286
Name:BOTTIZER RADIOLOGICAL PC
Entity Type:Organization
Organization Name:BOTTIZER RADIOLOGICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOTTIZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-872-7001
Mailing Address - Street 1:201 PORTION RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4172
Mailing Address - Country:US
Mailing Address - Phone:516-872-7001
Mailing Address - Fax:516-872-7007
Practice Address - Street 1:201 PORTION RD
Practice Address - Street 2:SUITE B
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4172
Practice Address - Country:US
Practice Address - Phone:516-872-7001
Practice Address - Fax:516-872-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114648-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty