Provider Demographics
NPI:1578508925
Name:BOTTROS, ISIS W (MD)
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:W
Last Name:BOTTROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:8836 N 23RD AVE
Practice Address - Street 2:B1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4185
Practice Address - Country:US
Practice Address - Phone:602-944-9810
Practice Address - Fax:602-216-7040
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1530182084P0800X
AZ511402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB75632Medicare UPIN
NY31104QMedicare ID - Type Unspecified
NYJ400049234/GPR70008AMedicare PIN
NY00783037Medicaid
NYJ400049237/GRPBA0017Medicare PIN