Provider Demographics
NPI:1760724074
Name:BOTROS, PAUL A (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:BOTROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 4TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-5606
Mailing Address - Country:US
Mailing Address - Phone:717-274-0474
Mailing Address - Fax:
Practice Address - Street 1:30 N 4TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17046-5606
Practice Address - Country:US
Practice Address - Phone:717-274-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD459527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103219609Medicaid
PA103219609Medicaid