Provider Demographics
NPI:1134252349
Name:BOTNER, BRYAN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KEITH
Last Name:BOTNER
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 1:1801 LEE RD STE 165
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2127
Mailing Address - Country:US
Mailing Address - Phone:407-922-7691
Mailing Address - Fax:407-975-0407
Practice Address - Street 1:1801 LEE RD STE 165
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2127
Practice Address - Country:US
Practice Address - Phone:407-922-7691
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY298992081S0010X
FLME119694208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43105OtherANTHEM BC AND BS
KY43105OtherANTHEM BC AND BS
F61950Medicare UPIN