Provider Demographics
NPI:1831105360
Name:BOTTA, JOSEPH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:BOTTA
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 1:24 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1906
Mailing Address - Country:US
Mailing Address - Phone:860-315-9026
Mailing Address - Fax:860-315-9142
Practice Address - Street 1:24 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1906
Practice Address - Country:US
Practice Address - Phone:860-315-9026
Practice Address - Fax:860-315-9142
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040605207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010040605CT01OtherANTHEM BCBS
CT1406059Medicaid
CT2V2749OtherHEALTHNET
CT010040605CT01OtherANTHEM BCBS
CT1406059Medicaid