Provider Demographics
NPI:1134179401
Name:BOTROS, NANCY (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BOTROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N MOUNTAIN
Mailing Address - Street 2:SUITE 112
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-931-1313
Mailing Address - Fax:909-920-3883
Practice Address - Street 1:440 N MOUNTAIN
Practice Address - Street 2:SUITE 112
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-931-1313
Practice Address - Fax:909-920-3883
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA045610208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A456100OtherMEDI CAL