Provider Demographics
NPI:1942732748
Name:BOTTA, JULIAN SEBASTIAN
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:SEBASTIAN
Last Name:BOTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 DICKERSON RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2816
Mailing Address - Country:US
Mailing Address - Phone:201-645-3735
Mailing Address - Fax:
Practice Address - Street 1:1830 E MONUMENT ST # MD21287
Practice Address - Street 2:SUITE 6‐100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0020
Practice Address - Country:US
Practice Address - Phone:201-645-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0090080207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program