Provider Demographics
NPI:1861499709
Name:BOTTO, RICHARD DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVID
Last Name:BOTTO
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 1:2130 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6405
Mailing Address - Country:US
Mailing Address - Phone:530-541-3277
Mailing Address - Fax:530-541-6913
Practice Address - Street 1:2130 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6405
Practice Address - Country:US
Practice Address - Phone:530-541-3277
Practice Address - Fax:530-541-6913
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44574207Q00000X
NV15008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01029Medicare PIN
E01212Medicare UPIN
CABZ993ZMedicare PIN