Provider Demographics
NPI:1942210349
Name:BOTTENBERG, B ALAN (DO)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:ALAN
Last Name:BOTTENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 N CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-1936
Mailing Address - Country:US
Mailing Address - Phone:775-883-3953
Mailing Address - Fax:775-885-2785
Practice Address - Street 1:550 W WASHINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3829
Practice Address - Country:US
Practice Address - Phone:775-883-3953
Practice Address - Fax:775-885-2785
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002013067Medicaid
NVF77726Medicare UPIN
NV002013067Medicaid