Provider Demographics
NPI:1821048687
Name:BOTLA, BUDEIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:BUDEIAH
Middle Name:
Last Name:BOTLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 WINTHROP AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1405
Mailing Address - Country:US
Mailing Address - Phone:630-856-6865
Mailing Address - Fax:630-856-6813
Practice Address - Street 1:701 WINTHROP AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-1405
Practice Address - Country:US
Practice Address - Phone:630-545-5980
Practice Address - Fax:630-545-5984
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36056318207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD14791Medicare UPIN