Provider Demographics
NPI:1902198500
Name:BOTWIN, JEREMY (OD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BOTWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7620
Mailing Address - Country:US
Mailing Address - Phone:505-954-4442
Mailing Address - Fax:505-954-4442
Practice Address - Street 1:444 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7620
Practice Address - Country:US
Practice Address - Phone:505-954-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-15
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA102894Medicare PIN