Provider Demographics
NPI:1982661344
Name:BOTHA, JEAN F (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:F
Last Name:BOTHA
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 1:5171 S COTTONWOOD ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5718
Mailing Address - Country:US
Mailing Address - Phone:801-507-3380
Mailing Address - Fax:385-297-2048
Practice Address - Street 1:5171 S COTTONWOOD ST STE 210
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5718
Practice Address - Country:US
Practice Address - Phone:801-507-3380
Practice Address - Fax:385-297-2048
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22313204F00000X
UT12742339-1205204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557580Medicaid
NEH71828Medicare UPIN
NE47078557580Medicaid