Provider Demographics
NPI:1689717290
Name:BOTELLO, ALEJANDRO I
Entity Type:Individual
Prefix:MR
First Name:ALEJANDRO
Middle Name:
Last Name:BOTELLO
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-7757
Mailing Address - Country:US
Mailing Address - Phone:903-938-8209
Mailing Address - Fax:903-938-8461
Practice Address - Street 1:114 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-7757
Practice Address - Country:US
Practice Address - Phone:903-938-8209
Practice Address - Fax:903-938-8461
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3-20083-3144-2171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor