Provider Demographics
NPI:1477551851
Name:BOTTIZER, WALTER E (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:E
Last Name:BOTTIZER
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 1:210 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2901
Mailing Address - Country:US
Mailing Address - Phone:914-682-6538
Mailing Address - Fax:914-682-6403
Practice Address - Street 1:1 THEALL RD
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:NY
Practice Address - Zip Code:10580-1404
Practice Address - Country:US
Practice Address - Phone:914-848-8850
Practice Address - Fax:914-682-6403
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1146482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00598889Medicaid
NYA400088963Medicare PIN
NYA63058Medicare UPIN
NY51A841Medicare ID - Type Unspecified
NYG400091721Medicare PIN