Provider Demographics
NPI:1679893374
Name:MEJIA BOTERO, MARIANA (MD)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:MEJIA BOTERO
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:PARAJE
Mailing Address - State:NM
Mailing Address - Zip Code:87007-0549
Mailing Address - Country:US
Mailing Address - Phone:505-431-0711
Mailing Address - Fax:
Practice Address - Street 1:6 BASSWOOD RD
Practice Address - Street 2:
Practice Address - City:PARAJE
Practice Address - State:NM
Practice Address - Zip Code:87007-1004
Practice Address - Country:US
Practice Address - Phone:505-431-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-0719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM78721016Medicaid