Provider Demographics
NPI:1548210834
Name:BOTU, BANKOLE O (MD)
Entity Type:Individual
Prefix:DR
First Name:BANKOLE
Middle Name:O
Last Name:BOTU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:289 IRELAND AVE
Mailing Address - Street 2:BLDG. 851 WTC UNIT
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5111
Mailing Address - Country:US
Mailing Address - Phone:502-624-9844
Mailing Address - Fax:502-624-9578
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:BLDG. 851 WTC UNIT
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9844
Practice Address - Fax:502-624-9578
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY33272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64034242Medicaid
KY64034242Medicaid