Provider Demographics
NPI:1639293558
Name:BOTIE, LAURIE B (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:B
Last Name:BOTIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1699
Mailing Address - Country:US
Mailing Address - Phone:978-453-9272
Mailing Address - Fax:978-970-1506
Practice Address - Street 1:600 CLARK RD
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1699
Practice Address - Country:US
Practice Address - Phone:978-453-9272
Practice Address - Fax:978-970-1506
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6727439OtherCIGNA HEALTHCARE
MAB46048OtherBL CRS BL SHLD INDIV #
MA701208OtherTUFTS
MA7662OtherHARVARD PILGRIM
MA92117OtherAETNA INDIVIDUAL #
MA01-00704OtherUNITED HEALTHCARE
NH30002667OtherMEDICAID NEW HAMPSHIRE
MA0154008Medicaid
MAB46048OtherBL CRS BL SHLD INDIV #
MAB73173Medicare UPIN