Provider Demographics
NPI:1295098143
Name:BOTERO, GINA P
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:P
Last Name:BOTERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5133 GOLDSMITH ST
Mailing Address - Street 2:APT 3H
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4265
Mailing Address - Country:US
Mailing Address - Phone:347-247-6156
Mailing Address - Fax:718-565-2836
Practice Address - Street 1:60 MADISON AVE
Practice Address - Street 2:8 FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1600
Practice Address - Country:US
Practice Address - Phone:212-684-0099
Practice Address - Fax:212-679-5891
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1833429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist