Provider Demographics
NPI:1760659130
Name:BOTT, WESLEY S (DO)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:S
Last Name:BOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:325 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2060
Mailing Address - Country:US
Mailing Address - Phone:801-798-7301
Mailing Address - Fax:801-798-8513
Practice Address - Street 1:94 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655-5655
Practice Address - Country:US
Practice Address - Phone:801-754-3122
Practice Address - Fax:801-754-0197
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02003547A207Q00000X
UT7925403-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000074112Medicare PIN
IN048580Q2Medicare PIN