Provider Demographics
NPI:1780650549
Name:BOTNEY, MITCHELL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:DAVID
Last Name:BOTNEY
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 1:3009 N BALLAS
Mailing Address - Street 2:256C
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-692-2788
Mailing Address - Fax:314-692-2228
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:256C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-692-2228
Practice Address - Fax:314-692-2017
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5G45207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO290011597OtherRAILROAD MEDICARE
MO202402947Medicaid
MOMA1354001Medicare PIN
MO290011597OtherRAILROAD MEDICARE
MO940984930Medicare PIN