Provider Demographics
NPI:1558386607
Name:BOTT-KOTHARI, TERRI LYNN (MD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:BOTT-KOTHARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:LYNN
Other - Last Name:BOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:5950 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9514
Practice Address - Country:US
Practice Address - Phone:616-252-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0773592085R0001X
MI43010773592085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4284064Medicaid
MI920006063OtherRAILROAD MEDICARE
MID16289011Medicare PIN
MIH33290Medicare UPIN
MI4284064Medicaid