Provider Demographics
NPI:1245255561
Name:BOTTEI, GREGORY MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MATTHEW
Last Name:BOTTEI
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 1:610 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3426
Mailing Address - Country:US
Mailing Address - Phone:920-437-7206
Mailing Address - Fax:
Practice Address - Street 1:610 N BROADWAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3426
Practice Address - Country:US
Practice Address - Phone:920-437-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32523500Medicaid
E92180Medicare UPIN
07125-0086Medicare ID - Type Unspecified