Provider Demographics
NPI:1689859704
Name:BOTTELSON, MARK LEROY (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEROY
Last Name:BOTTELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 73RD ST
Mailing Address - Street 2:VISION CENTER
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50324-1311
Mailing Address - Country:US
Mailing Address - Phone:515-274-6452
Mailing Address - Fax:515-274-6306
Practice Address - Street 1:1001 73RD ST
Practice Address - Street 2:VISION CENTER
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1311
Practice Address - Country:US
Practice Address - Phone:515-274-6452
Practice Address - Fax:515-274-6306
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA238377OtherCOVENTRY