Provider Demographics
NPI:1477622132
Name:BOTHOF, MICHAEL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BOTHOF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16298 HARMONY PATH
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6310
Mailing Address - Country:US
Mailing Address - Phone:952-953-4740
Mailing Address - Fax:
Practice Address - Street 1:16154 MAIN AVE SE STE 134A
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-4815
Practice Address - Country:US
Practice Address - Phone:952-447-3000
Practice Address - Fax:952-447-3561
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3631111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44-02426OtherMEDICA PROVIDER #
MN870G2BOOtherBLUE CROSS BLUE SHIELD MN
MNHP58905OtherHEALTH PARTNERS ID#
MN642613100Medicaid
MN44-02425OtherMEDICA
MN640618OtherACN CHIROCARE
MN44-02426OtherMEDICA PROVIDER #
MNU76917Medicare UPIN