Provider Demographics
NPI:1013971209
Name:BOTTGER, DAVID AVERY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:AVERY
Last Name:BOTTGER
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 1:3855 W CHESTER PIKE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2304
Mailing Address - Country:US
Mailing Address - Phone:610-355-1929
Mailing Address - Fax:610-355-1926
Practice Address - Street 1:3855 W CHESTER PIKE
Practice Address - Street 2:SUITE 230
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2304
Practice Address - Country:US
Practice Address - Phone:610-355-1929
Practice Address - Fax:610-355-1926
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045572E208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000612038OtherPA BLUE SHIELD
PA0440161000OtherKEYSTONE HEALTHPLAN
PA1046353003OtherCIGNA
PA99581OtherAETNA HEALTHCARE
PA000612038OtherPA BLUE SHIELD
PA612038Medicare ID - Type UnspecifiedMEDICARE