Provider Demographics
NPI:1891764577
Name:BOTLER, JOEL L (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:L
Last Name:BOTLER
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 1:100 FODEN RD, WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2319
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8597
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010885207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010554OtherANTHEM
1040536OtherAETNA
ME290910099Medicaid
B86547Medicare UPIN
015188Medicare ID - Type Unspecified
010554OtherANTHEM
ME01518802Medicare PIN
ME290910099Medicaid